Provider Demographics
NPI:1154670453
Name:LEWIS, ELLEN JO (BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:JO
Last Name:LEWIS
Suffix:
Gender:F
Credentials:BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S CATALINA ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3629
Mailing Address - Country:US
Mailing Address - Phone:805-477-8407
Mailing Address - Fax:
Practice Address - Street 1:126 S H ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6821
Practice Address - Country:US
Practice Address - Phone:805-979-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-08-4425103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12375700OtherCAQH