Provider Demographics
NPI:1689614786
Name:ELIAS, EVALYNNE GOULD (MSSW)
Entity Type:Individual
Prefix:
First Name:EVALYNNE
Middle Name:GOULD
Last Name:ELIAS
Suffix:
Gender:F
Credentials:MSSW
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 24468
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40524-4468
Mailing Address - Country:US
Mailing Address - Phone:859-273-7185
Mailing Address - Fax:859-273-7185
Practice Address - Street 1:4713 SUNNY PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-1584
Practice Address - Country:US
Practice Address - Phone:859-273-7185
Practice Address - Fax:859-273-7185
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCSW0195Medicare PIN