MEDICARE: DR. ELLEN KHAMISTOS WEISSMAN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	103TC0700X	Clinical Psychologist	24880	CA

General Provider Information

NPI Number	:	1811013881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN KHAMISTOS WEISSMAN PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 1968
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91376-1968
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5706 CORSA AVE STE 200I
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-4057
Country	:	US
Telephone Number	:	818-336-1041
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	04/05/2021

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