Provider Demographics
NPI:1992047724
Name:SPEYER, ELLEN V (MA MS MFT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:V
Last Name:SPEYER
Suffix:
Gender:F
Credentials:MA MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 660
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2030
Mailing Address - Country:US
Mailing Address - Phone:949-252-1525
Mailing Address - Fax:949-851-4347
Practice Address - Street 1:4590 MACARTHUR BLVD
Practice Address - Street 2:SUITE 660
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2030
Practice Address - Country:US
Practice Address - Phone:949-252-1525
Practice Address - Fax:949-851-4347
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24665106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist