Provider Demographics
NPI:1841025616
Name:CLANCY, ELLIE ROSE
Entity type:Individual
Prefix:
First Name:ELLIE ROSE
Middle Name:
Last Name:CLANCY
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 1:825 S HILL ST APT 522
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-3198
Mailing Address - Country:US
Mailing Address - Phone:818-205-6465
Mailing Address - Fax:
Practice Address - Street 1:11303 W WASHINGTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:310-482-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146015106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist