Provider Demographics
NPI:1548542962
Name:PETRISCA, ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PETRISCA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GOODRICH BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90022-5103
Mailing Address - Country:US
Mailing Address - Phone:213-832-9795
Mailing Address - Fax:
Practice Address - Street 1:1000 GOODRICH BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022
Practice Address - Country:US
Practice Address - Phone:213-832-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 225400000X, 225C00000X
CAPSY30521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor