Healthcare Provider Details

I. General information

NPI: 1740942374
Provider Name (Legal Business Name): ELIZABETH ERIN SUMNER BALLANTYNE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 10/11/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

IV. Provider business mailing address

131 EL SERENO DR
SCOTTS VALLEY CA
95066-4703
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-5555
  • Fax:
Mailing address:
  • Phone: 510-918-2536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number80094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: