Provider Demographics
NPI:1992201974
Name:ELLEN MENTAL HEALTH INC
Entity Type:Organization
Organization Name:ELLEN MENTAL HEALTH INC
Other - Org Name:WYLMA GIBBS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MARRIAGE FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:WYLMA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MFC49020
Authorized Official - Phone:626-827-0418
Mailing Address - Street 1:5626 SULTANA AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-2374
Mailing Address - Country:US
Mailing Address - Phone:626-827-0418
Mailing Address - Fax:
Practice Address - Street 1:5626 SULTANA AVE APT 3
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-2374
Practice Address - Country:US
Practice Address - Phone:626-827-0418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49020106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295867901Medicaid