Provider Demographics
NPI:1275008955
Name:MCELVAINE, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MCELVAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30395
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-3006
Mailing Address - Country:US
Mailing Address - Phone:509-990-9096
Mailing Address - Fax:866-250-9566
Practice Address - Street 1:4119 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-5336
Practice Address - Country:US
Practice Address - Phone:509-990-9096
Practice Address - Fax:866-250-9566
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WABA61135821103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2174488Medicaid