Healthcare Provider Details

I. General information

NPI: 1730998782
Provider Name (Legal Business Name): ELIVE M STANLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 FORT BAKER DR SE APT 1
WASHINGTON DC
20020-7274
US

IV. Provider business mailing address

9950 W INDIAN SCHOOL RD UNIT 8
PHOENIX AZ
85037-5912
US

V. Phone/Fax

Practice location:
  • Phone: 240-244-4863
  • Fax: 443-513-2664
Mailing address:
  • Phone: 443-527-1423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number966854
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCN221201831
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: