Provider Demographics
NPI:1396192498
Name:EBOULE, ELCA MANUELA
Entity Type:Individual
Prefix:MRS
First Name:ELCA
Middle Name:MANUELA
Last Name:EBOULE
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 1:190 CIVIC CIR STE 210
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3635
Mailing Address - Country:US
Mailing Address - Phone:401-837-6078
Mailing Address - Fax:
Practice Address - Street 1:190 CIVIC CIR STE 210
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3635
Practice Address - Country:US
Practice Address - Phone:401-837-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS21090278103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst