Provider Demographics
NPI:1710594049
Name:ELLIS, MICHELLE LYNAE (BA, RBT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNAE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BA, RBT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNAE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 CORRIDOR RD UNIT 3929
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32004-7850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 CORRIDOR RD UNIT 3929
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32004-7850
Practice Address - Country:US
Practice Address - Phone:254-383-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GARBT-20-133340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician