Provider Demographics
NPI:1730438714
Name:ROESE, ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ROESE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 S PCH HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3737
Mailing Address - Country:US
Mailing Address - Phone:310-567-5975
Mailing Address - Fax:
Practice Address - Street 1:326 S PCH HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3737
Practice Address - Country:US
Practice Address - Phone:310-567-5975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS286731041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical