Provider Demographics
NPI:1487826285
Name:ELLENWOOD, LAURA (LMFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ELLENWOOD
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 1:4733 TORRANCE BLVD.
Mailing Address - Street 2:511
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-803-5454
Mailing Address - Fax:
Practice Address - Street 1:4199 CAMPUS DRIVE
Practice Address - Street 2:275
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612
Practice Address - Country:US
Practice Address - Phone:949-225-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29360106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist