Provider Demographics
NPI:1740492123
Name:MOULTHROP, ELISABETH ANN (MFT)
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:ANN
Last Name:MOULTHROP
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MOULTHROP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:2160 THE ALAMEDA
Mailing Address - Street 2:STE D
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1122
Mailing Address - Country:US
Mailing Address - Phone:408-231-7010
Mailing Address - Fax:408-248-9762
Practice Address - Street 1:2160 THE ALAMEDA
Practice Address - Street 2:STE D
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1122
Practice Address - Country:US
Practice Address - Phone:408-231-7010
Practice Address - Fax:408-248-9762
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38803106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist