Provider Demographics
NPI:1003028473
Name:ELLEDGE, ROBERTA MARGARET (LMFT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARGARET
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:R.
Other - Middle Name:MARGARET
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:819 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1113
Mailing Address - Country:US
Mailing Address - Phone:209-549-9608
Mailing Address - Fax:209-522-5700
Practice Address - Street 1:819 15TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1113
Practice Address - Country:US
Practice Address - Phone:209-549-9608
Practice Address - Fax:209-522-5700
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31467106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist