Provider Demographics
NPI:1922364900
Name:KO, ELI J
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:J
Last Name:KO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 HARBOR BLVD. SUITE 900
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4122
Mailing Address - Country:US
Mailing Address - Phone:714-869-7025
Mailing Address - Fax:
Practice Address - Street 1:3001 RED HILL AVE.
Practice Address - Street 2:BUILDING 1 SUITE 221
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-869-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT94549106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist