Provider Demographics
NPI:1306398854
Name:ELY, EVAN (LPCC, LICDC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:ELY
Suffix:
Gender:M
Credentials:LPCC, LICDC
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 55
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-0055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 W MAIN ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2979
Practice Address - Country:US
Practice Address - Phone:937-971-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1100146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional