Basic Information
Provider Information
NPI: 1003000878
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VEENSTRA
FirstName: ELLEN
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: M.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 312 E CEDAR AVE
Address2: UNIT J
City: BURBANK
State: CA
PostalCode: 915021463
CountryCode: US
TelephoneNumber: 6165606674
FaxNumber:  
Practice Location
Address1: 1540 E COLORADO ST
Address2:  
City: GLENDALE
State: CA
PostalCode: 912051514
CountryCode: US
TelephoneNumber: 8182447257
FaxNumber: 8182435431
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 09/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  Y Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


Home