Provider Demographics
NPI:1770009300
Name:ELLIOTT, LAUREL M (LMFT #141619)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:M
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LMFT #141619
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S ELLSWORTH AVE
Mailing Address - Street 2:PO BOX 1427
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-0857
Mailing Address - Country:US
Mailing Address - Phone:314-825-8166
Mailing Address - Fax:
Practice Address - Street 1:375 89TH ST
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1802
Practice Address - Country:US
Practice Address - Phone:650-301-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141619106H00000X
101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist