Provider Demographics
NPI:1447539077
Name:REA, ELIZABETH ANN (MA, MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:REA
Suffix:
Gender:F
Credentials:MA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9242
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-0242
Mailing Address - Country:US
Mailing Address - Phone:510-665-7864
Mailing Address - Fax:
Practice Address - Street 1:1480 LINCOLN AVE
Practice Address - Street 2:#8
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2084
Practice Address - Country:US
Practice Address - Phone:415-456-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-13
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF#58981106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist