Basic Information
| Provider Information | |||||||||
| NPI: | 1609135730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROPER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 14TH ST APT 164 | ||||||||
| Address2: | |||||||||
| City: | RAMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920652159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608771125 | ||||||||
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| Practice Location | |||||||||
| Address1: | 340 RANCHEROS DR STE 166 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920692980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607443672 | ||||||||
| FaxNumber: | 7607446182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2012 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 373790000 | 05 | CA | MEDICAID |