Provider Demographics
NPI:1477170454
Name:ELLIS, KACI R (RBT)
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:R
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 1:6010 NW 53RD TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-3325
Mailing Address - Country:US
Mailing Address - Phone:386-503-5098
Mailing Address - Fax:
Practice Address - Street 1:1408 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4020
Practice Address - Country:US
Practice Address - Phone:352-373-4411
Practice Address - Fax:352-373-4455
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-125139106E00000X
222Q00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist