Provider Demographics
NPI:1790145860
Name:KINCAID, ELLEN (BCABA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KINCAID
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH FL
Mailing Address - State:FL
Mailing Address - Zip Code:32136
Mailing Address - Country:US
Mailing Address - Phone:386-503-3439
Mailing Address - Fax:
Practice Address - Street 1:1443 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-3761
Practice Address - Country:US
Practice Address - Phone:386-503-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-02-0592222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist