Provider Demographics
NPI:1831433978
Name:ELY, TERESA M (LPC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:ELY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 ROUTE 23
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7508
Mailing Address - Country:US
Mailing Address - Phone:908-338-3578
Mailing Address - Fax:
Practice Address - Street 1:1581 ROUTE 23
Practice Address - Street 2:SUITE 1
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7508
Practice Address - Country:US
Practice Address - Phone:908-338-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00414600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor