Provider Demographics
NPI:1861802365
Name:ELY, MARK ASHTON (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ASHTON
Last Name:ELY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CPR 450 BOX 1227
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09705
Mailing Address - Country:BE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Practice Address - Street 2:UNIT 33100
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:DE
Practice Address - Phone:504-343-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA108691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical