Basic Information
| Provider Information | |||||||||
| NPI: | 1992201974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLEN MENTAL HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WYLMA GIBBS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5626 SULTANA AVE APT 3 | ||||||||
| Address2: | |||||||||
| City: | TEMPLE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917802374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268270418 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5626 SULTANA AVE APT 3 | ||||||||
| Address2: | |||||||||
| City: | TEMPLE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917802374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268270418 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2018 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIBBS | ||||||||
| AuthorizedOfficialFirstName: | WYLMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MARRIAGE FAMILY THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6268270418 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFC49020 | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC49020 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1295867901 | 05 | CA | MEDICAID |