Healthcare Provider Details

I. General information

NPI: 1770414849
Provider Name (Legal Business Name): ELISA KINGSBURY M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 8TH ST
BERKELEY CA
94710-1434
US

IV. Provider business mailing address

2020 BONAR ST STE 303
BERKELEY CA
94702-1793
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-6339
  • Fax:
Mailing address:
  • Phone: 510-644-6210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number10375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: