Provider Demographics
NPI:1124654496
Name:ELEY, DWAYNE L
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:L
Last Name:ELEY
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 1:1809 DARVILLE DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23663-1914
Mailing Address - Country:US
Mailing Address - Phone:757-328-3437
Mailing Address - Fax:
Practice Address - Street 1:1809 DARVILLE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23663-1914
Practice Address - Country:US
Practice Address - Phone:757-328-3437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704005346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health