Provider Demographics
NPI:1629814520
Name:VRYMOED, ELYSE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:VRYMOED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:
Other - Last Name:JUNG-VRYMOED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 94800
Mailing Address - Street 2:600 LINCOLN AVE
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109
Mailing Address - Country:US
Mailing Address - Phone:323-435-5957
Mailing Address - Fax:
Practice Address - Street 1:2400 MISSION ST # 208
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-1632
Practice Address - Country:US
Practice Address - Phone:626-765-1753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147027106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist