=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083733562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOYCE ELLEN CAROLL MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11925 WILSHIRE BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-6618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-569-9503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 PLAIN TRL
-----------------------------------------------------
City | TOPANGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90290-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-455-0402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 39145
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------