Provider Demographics
NPI:1578253514
Name:ELLENBURG, SHERI DAWN (RBT)
Entity Type:Individual
Prefix:
First Name:SHERI
Middle Name:DAWN
Last Name:ELLENBURG
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 1:1777 AVENUE OF THE STATES STE 106
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4779
Mailing Address - Country:US
Mailing Address - Phone:405-442-4940
Mailing Address - Fax:580-366-4628
Practice Address - Street 1:101 PARK AVE STE 1300
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-7216
Practice Address - Country:US
Practice Address - Phone:405-442-4940
Practice Address - Fax:580-366-4628
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23258287106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician