Healthcare Provider Details

I. General information

NPI: 1558610238
Provider Name (Legal Business Name): ELISSA GENSBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1466 LINCOLN AVE
SAN RAFAEL CA
94901-2021
US

IV. Provider business mailing address

1466 LINCOLN AVE
SAN RAFAEL CA
94901-2021
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-3755
  • Fax: 415-457-0849
Mailing address:
  • Phone: 415-457-3755
  • Fax: 415-457-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: