Provider Demographics
NPI:1649390972
Name:FLUCK, ELIZABETH ANN (MA,BC-DMT,LMFT,NCC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:FLUCK
Suffix:
Gender:F
Credentials:MA,BC-DMT,LMFT,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4925
Mailing Address - Country:US
Mailing Address - Phone:626-798-6793
Mailing Address - Fax:
Practice Address - Street 1:760 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4925
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
84933101Y00000X
2001-ADTR-891225600000X
CA45109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist