Provider Demographics
NPI:1033899059
Name:PROVENCIO, ELLYSE NICOLE
Entity Type:Individual
Prefix:
First Name:ELLYSE
Middle Name:NICOLE
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25102 COOPER VLY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-2320
Mailing Address - Country:US
Mailing Address - Phone:915-667-7306
Mailing Address - Fax:
Practice Address - Street 1:14235 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7718
Practice Address - Country:US
Practice Address - Phone:210-415-9626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician