Provider Demographics
NPI:1831648567
Name:ELLEN MARIE KWON, PSYD, INC, A PSYCH CORP
Entity Type:Organization
Organization Name:ELLEN MARIE KWON, PSYD, INC, A PSYCH CORP
Other - Org Name:ELLEN MILLER KWON, PSYD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:626-807-5451
Mailing Address - Street 1:65 N MADISON AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2049
Mailing Address - Country:US
Mailing Address - Phone:626-807-5451
Mailing Address - Fax:626-395-7751
Practice Address - Street 1:65 N MADISON AVE STE 405
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2049
Practice Address - Country:US
Practice Address - Phone:626-807-5451
Practice Address - Fax:626-395-7751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24302103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty