Healthcare Provider Details

I. General information

NPI: 1013420371
Provider Name (Legal Business Name): ETHAN EMERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6957 N FIGUEROA ST
LOS ANGELES CA
90042
US

IV. Provider business mailing address

17145 STRATHERN ST
VAN NUYS CA
91406-1019
US

V. Phone/Fax

Practice location:
  • Phone: 323-443-3175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF73183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: