Provider Demographics
NPI:1013551712
Name:ELY, NATHANIEL LAWRENCE
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:LAWRENCE
Last Name:ELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 W HUNTINGTON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1222
Mailing Address - Country:US
Mailing Address - Phone:626-775-7732
Mailing Address - Fax:
Practice Address - Street 1:1961 W HUNTINGTON DR STE 200
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1222
Practice Address - Country:US
Practice Address - Phone:626-775-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127630106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist