Provider Demographics
NPI:1902825961
Name:ELLIOTT, LAURA JESSICA (MA)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JESSICA
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SPRING GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2636
Mailing Address - Country:US
Mailing Address - Phone:415-454-8238
Mailing Address - Fax:415-454-6836
Practice Address - Street 1:711 D ST
Practice Address - Street 2:SUITE 212
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3707
Practice Address - Country:US
Practice Address - Phone:415-721-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31175106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist