Provider Demographics
NPI:1396360897
Name:HENNEBERG, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HENNEBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:HENNEBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8913 NE GOING ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4823
Mailing Address - Country:US
Mailing Address - Phone:775-560-4033
Mailing Address - Fax:
Practice Address - Street 1:1919 ADDISON ST STE 204
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1143
Practice Address - Country:US
Practice Address - Phone:775-560-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health