Provider Demographics
NPI:1720304561
Name:VON, ELENORA P (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ELENORA
Middle Name:P
Last Name:VON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15117 MAIN STREET
Mailing Address - Street 2:SUITE 205 #124
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012
Mailing Address - Country:US
Mailing Address - Phone:425-285-8338
Mailing Address - Fax:
Practice Address - Street 1:15117 MAIN STREET
Practice Address - Street 2:SUITE 205 #124
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012
Practice Address - Country:US
Practice Address - Phone:425-285-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60088199101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1982909Medicaid