Healthcare Provider Details

I. General information

NPI: 1265869200
Provider Name (Legal Business Name): ELIZABETH EMILY ECCLESTON MSW, ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PACIFIC COAST HWY SUITE 200A
REDONDO BEACH CA
90277-2162
US

IV. Provider business mailing address

715 S NORMANDIE AVE #520
LOS ANGELES CA
90005-2267
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-1610
  • Fax:
Mailing address:
  • Phone: 312-890-8496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW 33437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: