Provider Demographics
NPI:1679724520
Name:ELLIS, SHAYLA RENEE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SHAYLA
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:8027 COOPER CREEK BLVD STE 103
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:FL
Practice Address - Zip Code:34201-3002
Practice Address - Country:US
Practice Address - Phone:941-477-2080
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-08-4580103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024004496Medicaid