Provider Demographics
NPI:1669819421
Name:ELY, MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ELY
Suffix:
Gender:M
Credentials:LCSW
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 1029
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-1029
Mailing Address - Country:US
Mailing Address - Phone:907-543-6800
Mailing Address - Fax:907-543-7101
Practice Address - Street 1:115 ROCKWOOD LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9415
Practice Address - Country:US
Practice Address - Phone:800-575-7223
Practice Address - Fax:600-436-5797
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100397170Medicaid