Provider Demographics
NPI:1710015599
Name:LEY, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LEY
Suffix:
Gender:F
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 4752
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0197
Mailing Address - Country:US
Mailing Address - Phone:415-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:STE 208
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-6801
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL5017SR1041C0700X
CALCS119891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03906FMedicaid
CAFHC03906FMedicaid