Provider Demographics
NPI:1134694656
Name:BICE, CARLLIE JO-LOUISE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CARLLIE
Middle Name:JO-LOUISE
Last Name:BICE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:CARLLIE
Other - Middle Name:JO-LOUISE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:17390 DUGDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1512
Practice Address - Country:US
Practice Address - Phone:574-400-2169
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-42880103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-42880OtherBCBA CERTIFICATE