Healthcare Provider Details

I. General information

NPI: 1982070355
Provider Name (Legal Business Name): ELISE HUERTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 STOCKER ST
VIEW PARK CA
90008-5101
US

IV. Provider business mailing address

200 N SAN FERNANDO RD # LOFT409
LOS ANGELES CA
90031-1339
US

V. Phone/Fax

Practice location:
  • Phone: 323-298-3680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number67676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: