Provider Demographics
NPI:1720218761
Name:JOSEFSON, ELLIE
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:JOSEFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:JOSEFSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:17337 TRAMONTO DR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3121
Mailing Address - Country:US
Mailing Address - Phone:310-721-9886
Mailing Address - Fax:310-573-0345
Practice Address - Street 1:520 S SEPULVEDA BLVD STE 406
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3547
Practice Address - Country:US
Practice Address - Phone:310-721-9886
Practice Address - Fax:310-472-0333
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-24
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC # 47314106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist