Provider Demographics
NPI:1407618143
Name:SUBEGA, ELISABETH DESIMONE
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:DESIMONE
Last Name:SUBEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16695 SHANNON RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-4619
Mailing Address - Country:US
Mailing Address - Phone:083-489-6004
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2675
Practice Address - Country:US
Practice Address - Phone:408-559-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144580106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist