Provider Demographics
NPI:1174350813
Name:CORVO, ELISE (LMFT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:CORVO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-3126
Mailing Address - Country:US
Mailing Address - Phone:310-292-0722
Mailing Address - Fax:
Practice Address - Street 1:452 23RD ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-3126
Practice Address - Country:US
Practice Address - Phone:310-292-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist