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General NPI Number Information
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NPI Number | 1124361571
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Entity Type | Individual
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Provider Name | JOHN P ELY MFTI
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Gender | Male
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Dates
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Enumeration Date | 04/04/2013
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Last Update Date | 07/02/2013
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Provider Practice Location Address
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Address Line | 6302 THIRTEENTH AVE BOX 1024
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City | LUCERNE
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State | CA
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Zip | 95458-1024
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Country | US
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Telephone | 707-274-9101
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Fax |
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Provider Business Mailing Address
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Address Line | 9380 PALOOS CT
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City | KELSEYVILLE
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State | CA
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Zip | 95451-7804
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Country | US
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Telephone | 707-277-0848
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 75046
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License Number State | CA
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