Provider Demographics
NPI:1366980260
Name:ELY, MICHELLE MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:ELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-2301
Mailing Address - Country:US
Mailing Address - Phone:907-377-4041
Mailing Address - Fax:
Practice Address - Street 1:2630 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2301
Practice Address - Country:US
Practice Address - Phone:907-377-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW869781041C0700X
AK1654331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical