Provider Demographics
NPI:1508571019
Name:ELY, TENNEILLE (LMFT)
Entity Type:Individual
Prefix:
First Name:TENNEILLE
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 W BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2938
Mailing Address - Country:US
Mailing Address - Phone:309-692-7755
Mailing Address - Fax:
Practice Address - Street 1:3716 W BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2938
Practice Address - Country:US
Practice Address - Phone:309-692-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty