Healthcare Provider Details

I. General information

NPI: 1124543236
Provider Name (Legal Business Name): ELIZABETH KELISHADI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HAMPTON DR
VENICE CA
90291-8633
US

IV. Provider business mailing address

3045 SCHOLARSHIP
IRVINE CA
92612-4420
US

V. Phone/Fax

Practice location:
  • Phone: 310-396-6468
  • Fax: 310-392-8402
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberACSW90477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: