Provider Demographics
NPI:1831956911
Name:BERG, ELLEY TAYLOR ESTELLA
Entity type:Individual
Prefix:
First Name:ELLEY TAYLOR
Middle Name:ESTELLA
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W OLYMPIC BLVD STE 743
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 W OLYMPIC BLVD STE 743
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1668
Practice Address - Country:US
Practice Address - Phone:310-712-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist