Provider Demographics
NPI:1104943679
Name:ALBERTSON, ELLEN KAINOMARIA (PHD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:KAINOMARIA
Last Name:ALBERTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W IMPERIAL AVE
Mailing Address - Street 2:STE M
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2200
Mailing Address - Country:US
Mailing Address - Phone:310-210-4383
Mailing Address - Fax:310-322-4825
Practice Address - Street 1:100 W IMPERIAL AVE
Practice Address - Street 2:STE M
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2200
Practice Address - Country:US
Practice Address - Phone:310-210-4383
Practice Address - Fax:310-322-4825
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist