Provider Demographics
NPI:1093145120
Name:ZELLEFROW, MARK (BCBA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ZELLEFROW
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15023 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5024
Mailing Address - Country:US
Mailing Address - Phone:586-286-9644
Mailing Address - Fax:
Practice Address - Street 1:15023 21 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-5024
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
1-16-24832103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid