Healthcare Provider Details

I. General information

NPI: 1144028325
Provider Name (Legal Business Name): LISA ELSIE ELLIOTT AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 PROFESSIONAL DR STE A
SANTA ROSA CA
95403-3015
US

IV. Provider business mailing address

2117 ROSEMARY CT
PETALUMA CA
94954-4685
US

V. Phone/Fax

Practice location:
  • Phone: 707-483-9061
  • Fax:
Mailing address:
  • Phone: 707-486-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number142231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: