MEDICARE: MONICA ELLISON M.A., MFTI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	106H00000X	Marriage & Family Therapist	87526	CA
3	225400000X	Rehabilitation Practitioner
4	390200000X	Student in an Organized Health Care Education/Training Program	B9918768	CA
5	106H00000X	Marriage & Family Therapist	114191	CA

General Provider Information

NPI Number	:	1629238423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA ELLISON M.A., MFTI

Provider Business Mailing Address
First Line	:	5100 S EASTERN AVE STE 110
Second Line	:
City	:	COMMERCE
State	:	CA
Zip	:	90040-2964
Country	:	US
Telephone Number	:	323-347-0759
Fax Number	:

Provider Business Practice Location Address
First Line	:	1968 W ADAMS BLVD
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-3515
Country	:	US
Telephone Number	:	323-487-1989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2008
Last Update Date	:	07/17/2020

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