Provider Demographics
NPI:1053389163
Name:SHABO-ELBAUM, EVELYNE RUTH (MFC)
Entity type:Individual
Prefix:
First Name:EVELYNE
Middle Name:RUTH
Last Name:SHABO-ELBAUM
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14156 MAGNOLIA BLVD
Mailing Address - Street 2:105
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-6401
Mailing Address - Country:US
Mailing Address - Phone:818-986-0866
Mailing Address - Fax:818-881-0427
Practice Address - Street 1:14156 MAGNOLIA BLVD
Practice Address - Street 2:105
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-6401
Practice Address - Country:US
Practice Address - Phone:818-986-0866
Practice Address - Fax:818-881-0427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ14052ZOtherBLUE SHIELD
174359OtherVALUE OPTIONS
A897893OtherVENDOR ID
70072513OtherUNITED BEHAVIORAL HEALTH