Provider Demographics
NPI:1629438643
Name:TAN, ELLEN MARIE (MFT (CA))
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MARIE
Last Name:TAN
Suffix:
Gender:F
Credentials:MFT (CA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SO. CHELSEA RD. ELLEN M. TAN, MFT
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108
Mailing Address - Country:US
Mailing Address - Phone:626-458-2934
Mailing Address - Fax:
Practice Address - Street 1:1625 SO. CHELSEA RD. ELLEN M. TAN, MFT
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108
Practice Address - Country:US
Practice Address - Phone:626-458-2934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACALMFT#23227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist