Provider Demographics
NPI:1609095769
Name:THOMPSON, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 W 94TH ST
Mailing Address - Street 2:#4
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-1941
Mailing Address - Country:US
Mailing Address - Phone:323-779-5847
Mailing Address - Fax:323-759-6189
Practice Address - Street 1:1704 W MANCHESTER AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3034
Practice Address - Country:US
Practice Address - Phone:323-759-6224
Practice Address - Fax:323-759-6189
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5414101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)