Provider Demographics
NPI:1184210890
Name:ELLISON, KERA JO
Entity Type:Individual
Prefix:
First Name:KERA
Middle Name:JO
Last Name:ELLISON
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 1:1018 S BRUNDIDGE ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081-3148
Mailing Address - Country:US
Mailing Address - Phone:334-792-5020
Mailing Address - Fax:
Practice Address - Street 1:1018 S BRUNDIDGE ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081-3148
Practice Address - Country:US
Practice Address - Phone:334-792-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALRBT-20-146872OtherRBT-20-146872