Provider Demographics
NPI:1174196166
Name:ELLIOTT, KAETE LOUISE (MA,MDIV)
Entity type:Individual
Prefix:MS
First Name:KAETE
Middle Name:LOUISE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA,MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SAN FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-4733
Mailing Address - Country:US
Mailing Address - Phone:626-533-7004
Mailing Address - Fax:626-403-5950
Practice Address - Street 1:1910 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4886
Practice Address - Country:US
Practice Address - Phone:626-403-5950
Practice Address - Fax:626-540-3595
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist