Provider Demographics
NPI:1962767608
Name:ESPITIA, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ESPITIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ESPITIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8670 CAMINO COLEGIO, # 178
Mailing Address - Street 2:
Mailing Address - City:RONHERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928
Mailing Address - Country:US
Mailing Address - Phone:707-533-3953
Mailing Address - Fax:
Practice Address - Street 1:1500 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5545
Practice Address - Country:US
Practice Address - Phone:707-765-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist