Provider Demographics
NPI:1104543172
Name:ELY, ALEXIS (LPMC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:LPMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 AMITY ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6015
Mailing Address - Country:US
Mailing Address - Phone:248-808-2896
Mailing Address - Fax:
Practice Address - Street 1:86 AMITY ST APT 2R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6015
Practice Address - Country:US
Practice Address - Phone:248-808-2896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP113009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health