Provider Demographics
NPI:1538468392
Name:ELLIS, JAMES T (PHD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 BOSTON ST # 3
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1142
Mailing Address - Country:US
Mailing Address - Phone:978-806-1906
Mailing Address - Fax:
Practice Address - Street 1:461 RIVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4213
Practice Address - Country:US
Practice Address - Phone:978-654-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-05-2212103K00000X
MA7985103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst