Provider Demographics
NPI:1316458052
Name:ELLERBY, PICCERA TIFFANY (LMFT)
Entity type:Individual
Prefix:MRS
First Name:PICCERA TIFFANY
Middle Name:
Last Name:ELLERBY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3894 CRENSHAW BLVD UNIT 56781
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-3041
Mailing Address - Country:US
Mailing Address - Phone:310-853-2032
Mailing Address - Fax:
Practice Address - Street 1:5300 ANGELES VISTA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043
Practice Address - Country:US
Practice Address - Phone:310-853-2032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT119321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1977659Medicaid