Provider Demographics
NPI:1811965841
Name:ELY, CHRISTINE (MPT)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:BETHGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:785 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019
Mailing Address - Country:US
Mailing Address - Phone:650-712-8400
Mailing Address - Fax:650-712-8600
Practice Address - Street 1:785 MAIN ST
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1992
Practice Address - Country:US
Practice Address - Phone:650-712-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18744174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT18744OtherLICENSE #
CAPT18744OtherLICENSE #