Provider Demographics
NPI:1568127579
Name:ELDER, CODY DALTON (LMFT, APCC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:DALTON
Last Name:ELDER
Suffix:
Gender:M
Credentials:LMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2211
Mailing Address - Country:US
Mailing Address - Phone:949-629-3730
Mailing Address - Fax:
Practice Address - Street 1:4000 BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2211
Practice Address - Country:US
Practice Address - Phone:949-629-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty