Provider Demographics
NPI:1043550270
Name:WANTUCH, ELIZABETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:WANTUCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 VARDA LANDING RD
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1417
Mailing Address - Country:US
Mailing Address - Phone:415-847-1978
Mailing Address - Fax:
Practice Address - Street 1:56 VARDA LANDING RD
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1417
Practice Address - Country:US
Practice Address - Phone:415-847-1978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18779103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical