Provider Demographics
NPI:1679692362
Name:GAINES, ELIZABETH CHILTON (PSYD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHILTON
Last Name:GAINES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S ILLINOIS ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3644
Mailing Address - Country:US
Mailing Address - Phone:310-625-6408
Mailing Address - Fax:
Practice Address - Street 1:1702 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-2423
Practice Address - Country:US
Practice Address - Phone:310-625-6408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19272103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical