Provider Demographics
NPI:1417989088
Name:ELY, AUDREY R (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:R
Last Name:ELY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 VILLAGE AVE
Mailing Address - Street 2:APT 204
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4200
Mailing Address - Country:US
Mailing Address - Phone:781-461-1902
Mailing Address - Fax:
Practice Address - Street 1:859 WILLARD ST
Practice Address - Street 2:SUITE 430
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7482
Practice Address - Country:US
Practice Address - Phone:617-847-1976
Practice Address - Fax:617-786-9894
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1003331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP02359Medicare ID - Type Unspecified