Provider Demographics
NPI:1518260215
Name:ROSS, ELLIE (MFT)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 FLORESTA PL
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2350
Mailing Address - Country:US
Mailing Address - Phone:310-586-6995
Mailing Address - Fax:310-230-1773
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:310-586-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-18
Last Update Date:2010-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31639106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist