Provider Demographics
NPI:1376524827
Name:ELY, LINDA TAYLOR (RN, CNS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:TAYLOR
Last Name:ELY
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BROAD ST
Mailing Address - Street 2:P.O. BOX 1183
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-3201
Mailing Address - Country:US
Mailing Address - Phone:540-674-4506
Mailing Address - Fax:540-674-4507
Practice Address - Street 1:125 BROAD ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3201
Practice Address - Country:US
Practice Address - Phone:540-674-4506
Practice Address - Fax:540-674-4507
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015-000533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010146917Medicaid
VA010146917Medicaid