Healthcare Provider Details

I. General information

NPI: 1356771315
Provider Name (Legal Business Name): ELLEN MILLER KWON, PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N MADISON AVE SUITE 405
PASADENA CA
91101-2035
US

IV. Provider business mailing address

65 N MADISON AVE SUITE 405
PASADENA CA
91101-2035
US

V. Phone/Fax

Practice location:
  • Phone: 626-807-5451
  • Fax: 626-395-7751
Mailing address:
  • Phone: 626-807-5451
  • Fax: 626-395-7751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number24302
License Number StateCA

VIII. Authorized Official

Name: DR. ELLEN MARIE KWON
Title or Position: OWNER
Credential: PSY,D,
Phone: 626-807-5451