Healthcare Provider Details

I. General information

NPI: 1124361571
Provider Name (Legal Business Name): JOHN P ELY MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 THIRTEENTH AVE BOX 1024
LUCERNE CA
95458-1024
US

IV. Provider business mailing address

9380 PALOOS CT
KELSEYVILLE CA
95451-7804
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9101
  • Fax:
Mailing address:
  • Phone: 707-277-0848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number75046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: