Provider Demographics
NPI:1114405479
Name:SIX, ELIZABETH ROXANNE KELSO (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ROXANNE KELSO
Last Name:SIX
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ROXANNE
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:2339 N CALIFORNIA AVE UNIT 47949
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-0360
Mailing Address - Country:US
Mailing Address - Phone:773-595-6786
Mailing Address - Fax:773-305-8082
Practice Address - Street 1:3048 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6624
Practice Address - Country:US
Practice Address - Phone:773-595-6786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-30563103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst