Provider Demographics
NPI:1780023762
Name:ELY, POLLY S (MFT)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:S
Last Name:ELY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:S
Other - Last Name:ELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 685
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-0685
Mailing Address - Country:US
Mailing Address - Phone:415-706-7637
Mailing Address - Fax:
Practice Address - Street 1:145 ESPERANZA ST
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-1914
Practice Address - Country:US
Practice Address - Phone:415-233-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-22
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist