Healthcare Provider Details

I. General information

NPI: 1295397578
Provider Name (Legal Business Name): ELIZABETH MAE GENDRON MAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25402 PACIFICA AVE
MISSION VIEJO CA
92691-3854
US

IV. Provider business mailing address

25402 PACIFICA AVE
MISSION VIEJO CA
92691-3854
US

V. Phone/Fax

Practice location:
  • Phone: 949-238-2400
  • Fax: 949-860-7924
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA2710
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: