Provider Demographics
NPI:1831376755
Name:ELY, LAURA JANET (PHD, LCP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JANET
Last Name:ELY
Suffix:
Gender:F
Credentials:PHD, LCP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:ELY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD , LCP
Mailing Address - Street 1:3400 KIM CT APT A15
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5090
Mailing Address - Country:US
Mailing Address - Phone:662-801-3359
Mailing Address - Fax:
Practice Address - Street 1:1402 GRANDIN RD SW STE 211
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2348
Practice Address - Country:US
Practice Address - Phone:540-655-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004782103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical