Provider Demographics
NPI:1568707552
Name:MARSHALL, ELIZABETH STACEY (MFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:STACEY
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8474 CHRISTOPHER RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-6143
Mailing Address - Country:US
Mailing Address - Phone:858-335-9833
Mailing Address - Fax:
Practice Address - Street 1:8474 CHRISTOPHER RIDGE TER
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-6143
Practice Address - Country:US
Practice Address - Phone:858-335-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN