Healthcare Provider Details

I. General information

NPI: 1306284260
Provider Name (Legal Business Name): ELYSE LANZNER GONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELYSE CARISSA LANZNER LCSW

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 ARLINGTON AVE
BERKELEY CA
94707-1929
US

IV. Provider business mailing address

PO BOX 8445
BERKELEY CA
94707-8445
US

V. Phone/Fax

Practice location:
  • Phone: 510-200-8426
  • Fax:
Mailing address:
  • Phone: 510-200-8426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number77277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: