Provider Demographics
NPI:1568857225
Name:ELLIS-WOROCH, BARBARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:
Last Name:ELLIS-WOROCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:
Other - Last Name:ELLIS-WOROCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:415 N RICHARD JACKSON BLVD STE 209
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3694
Mailing Address - Country:US
Mailing Address - Phone:850-866-0441
Mailing Address - Fax:850-254-0827
Practice Address - Street 1:415 N RICHARD JACKSON BLVD STE 209
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3694
Practice Address - Country:US
Practice Address - Phone:850-866-0441
Practice Address - Fax:850-254-0827
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-254-61103K00000X
FL1-17-25461103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104870300Medicaid