Healthcare Provider Details

I. General information

NPI: 1477679199
Provider Name (Legal Business Name): ELIDA B OETTEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CABRILLO HWY S 200A
HALF MOON BAY CA
94019-8200
US

IV. Provider business mailing address

225 CABRILLO HWY S 200A
HALF MOON BAY CA
94019-8200
US

V. Phone/Fax

Practice location:
  • Phone: 650-363-4535
  • Fax:
Mailing address:
  • Phone: 650-455-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS17650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: