Healthcare Provider Details

I. General information

NPI: 1528129848
Provider Name (Legal Business Name): ELENA KUDELIN MA, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 LYTTON AVE SUITE 1
PALO ALTO CA
94301-1335
US

IV. Provider business mailing address

665 LYTTON AVE SUITE 1
PALO ALTO CA
94301-1335
US

V. Phone/Fax

Practice location:
  • Phone: 650-266-8212
  • Fax:
Mailing address:
  • Phone: 650-266-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number47182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: