Healthcare Provider Details

I. General information

NPI: 1255356580
Provider Name (Legal Business Name): MS. ELIZABETH DONAHUE-MARUCHEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIZ DONAHUE LCSW

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 LAKE PARK WAY #114
LA MESA CA
91942-1664
US

IV. Provider business mailing address

5575 LAKE PARK WAY #114
LA MESA CA
91942-1664
US

V. Phone/Fax

Practice location:
  • Phone: 858-467-5454
  • Fax: 619-463-8986
Mailing address:
  • Phone: 858-467-5454
  • Fax: 619-463-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS14756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: