Provider Demographics
NPI:1124512363
Name:FROISTAD, ELISE (MFT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:FROISTAD
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 1:1151 DOVE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2805
Mailing Address - Country:US
Mailing Address - Phone:949-734-0458
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE ST STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2805
Practice Address - Country:US
Practice Address - Phone:949-734-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37402106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist