Provider Demographics
NPI:1720425473
Name:MONTROSE-ROBACK, ELISA MARLENE (LMFT)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARLENE
Last Name:MONTROSE-ROBACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:MARLENE
Other - Last Name:MONTROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:7013 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6639
Mailing Address - Country:US
Mailing Address - Phone:505-503-6838
Mailing Address - Fax:
Practice Address - Street 1:7013 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6639
Practice Address - Country:US
Practice Address - Phone:505-503-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0090041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist