Provider Demographics
NPI:1326719493
Name:ELLIS, FEDRICKA ADRIANA (RBT)
Entity Type:Individual
Prefix:MISS
First Name:FEDRICKA
Middle Name:ADRIANA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33311-4227
Mailing Address - Country:US
Mailing Address - Phone:954-683-8090
Mailing Address - Fax:
Practice Address - Street 1:1554 ORION LN
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-2327
Practice Address - Country:US
Practice Address - Phone:954-683-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-95091106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103791800Medicaid