Provider Demographics
NPI:1194095505
Name:ELIAS, EDY LYNN (MFC)
Entity type:Individual
Prefix:MS
First Name:EDY
Middle Name:LYNN
Last Name:ELIAS
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2008
Mailing Address - Country:US
Mailing Address - Phone:510-504-2957
Mailing Address - Fax:
Practice Address - Street 1:1516 DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2008
Practice Address - Country:US
Practice Address - Phone:510-504-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist