Provider Demographics
NPI:1689107716
Name:ELLISH, NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ELLISH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SPIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:10450 72ND AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2911
Practice Address - Country:US
Practice Address - Phone:262-657-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11725028103K00000X
WI176-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst