Provider Demographics
NPI:1417030800
Name:ALVAREZ, ELAINE COSTANZO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:COSTANZO
Last Name:ALVAREZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17075 DEVONSHIRE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5408
Mailing Address - Country:US
Mailing Address - Phone:818-710-8057
Mailing Address - Fax:818-368-8940
Practice Address - Street 1:18546 ROSCOE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-5454
Practice Address - Country:US
Practice Address - Phone:818-710-8057
Practice Address - Fax:818-710-8042
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5342103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5342Medicare ID - Type Unspecified