Provider Demographics
NPI:1811219405
Name:STORM, ELIZABETH JANE (MFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:STORM
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 1:5350 OLD REDWOOD HWY NORTH
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-565-7819
Mailing Address - Fax:
Practice Address - Street 1:3270 KERNER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-473-3486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51181106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health