Provider Demographics
NPI:1588227359
Name:ELY, MEGAN CAROLINA
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CAROLINA
Last Name:ELY
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 1:91150 N COBURG INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9512
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:
Practice Address - Street 1:91150 N COBURG INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9512
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-21-1250101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)