Provider Demographics
NPI:1013150937
Name:OWENS, ELISA SHANAE
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:SHANAE
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:SHANAE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3756 SANTA ROSALIA DR
Mailing Address - Street 2:507
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3606
Mailing Address - Country:US
Mailing Address - Phone:323-290-2001
Mailing Address - Fax:323-290-2003
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:SUITE 507
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-290-2001
Practice Address - Fax:323-290-2003
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA722207101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA722207OtherALCOHOL AND DRUG COUNSELOR