Provider Demographics
NPI:1972635779
Name:KIMMEL, ELLEN R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:R
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 WASHINGTON BLVS. #815
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292
Mailing Address - Country:US
Mailing Address - Phone:323-447-8372
Mailing Address - Fax:
Practice Address - Street 1:578 WASHINGTON BLVD # 815
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5442
Practice Address - Country:US
Practice Address - Phone:323-447-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS113871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical