Provider Demographics
NPI:1407613706
Name:ELLICK, LUCRETIA ANASTASIA
Entity Type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:ANASTASIA
Last Name:ELLICK
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 1:1441 WELTON CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-3039
Mailing Address - Country:US
Mailing Address - Phone:404-484-2557
Mailing Address - Fax:
Practice Address - Street 1:1441 WELTON CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-3039
Practice Address - Country:US
Practice Address - Phone:404-484-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician