Provider Demographics
NPI:1124361571
Name:ELY, JOHN P (MFTI)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:ELY
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9380 PALOOS CT
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-7804
Mailing Address - Country:US
Mailing Address - Phone:707-277-0848
Mailing Address - Fax:
Practice Address - Street 1:6302 THIRTEENTH AVE
Practice Address - Street 2:BOX 1024
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458-1024
Practice Address - Country:US
Practice Address - Phone:707-274-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75046OtherINTERN- MARRIAGE AND FAMILY THERAPIST