Provider Demographics
NPI:1417038928
Name:WITH, ELAINE W (MS)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:W
Last Name:WITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 BOULEVARD WAY # 308
Mailing Address - Street 2:# 308
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595
Mailing Address - Country:US
Mailing Address - Phone:925-937-1245
Mailing Address - Fax:
Practice Address - Street 1:1280 BOULEVARD WAY # 308
Practice Address - Street 2:# 308
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595
Practice Address - Country:US
Practice Address - Phone:925-937-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30515106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MFC30515Medicare UPIN