Provider Demographics
NPI:1356550933
Name:ROTH, ELLEN NAN (MFC)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:NAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:NAN
Other - Last Name:ROTH-JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:935 WESTBOURNE DR
Mailing Address - Street 2:#202
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4154
Mailing Address - Country:US
Mailing Address - Phone:310-855-0223
Mailing Address - Fax:
Practice Address - Street 1:935 WESTBOURNE DR
Practice Address - Street 2:#202
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4154
Practice Address - Country:US
Practice Address - Phone:310-855-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 16583106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist