Provider Demographics
NPI:1962626481
Name:LOVELY, ELIZABETH RECKTENWALD (L MFT, AT)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RECKTENWALD
Last Name:LOVELY
Suffix:
Gender:F
Credentials:L MFT, AT
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:NICOLE
Other - Last Name:RECKTENWALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA MFT-I, AT
Mailing Address - Street 1:PO BOX 7533
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95150-7533
Mailing Address - Country:US
Mailing Address - Phone:408-761-5705
Mailing Address - Fax:
Practice Address - Street 1:544 VALLEY WAY
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-4106
Practice Address - Country:US
Practice Address - Phone:408-493-5289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC# 48520106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF # 47694OtherBBS MFT INTERN REG NUMBER
CAMFC#48520OtherBOARD OF BEHAVIORAL SERVICES