Provider Demographics
NPI:1982056040
Name:IANNACCONE, ELIZABETH (LMFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:IANNACCONE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-0602
Mailing Address - Country:US
Mailing Address - Phone:925-890-8461
Mailing Address - Fax:
Practice Address - Street 1:8385 BRENTWOOD BLVD STE A
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-1381
Practice Address - Country:US
Practice Address - Phone:925-516-9970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40352106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist