Provider Demographics
NPI:1093854853
Name:ELY, RENE J (LMFT)
Entity Type:Individual
Prefix:MR
First Name:RENE
Middle Name:J
Last Name:ELY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1218
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1218
Mailing Address - Country:US
Mailing Address - Phone:678-520-7476
Mailing Address - Fax:770-978-7676
Practice Address - Street 1:1790 CENTURY BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3322
Practice Address - Country:US
Practice Address - Phone:404-671-9226
Practice Address - Fax:770-978-7676
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAMFT000908106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA799255930AMedicaid