Provider Demographics
NPI:1790274330
Name:MILLESON, ELLEN (RBT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MILLESON
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 1:9357 PHILIPS HWY STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1368
Mailing Address - Country:US
Mailing Address - Phone:904-683-4226
Mailing Address - Fax:904-212-2823
Practice Address - Street 1:9357 PHILIPS HWY STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1368
Practice Address - Country:US
Practice Address - Phone:904-683-4226
Practice Address - Fax:904-212-2823
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18-54575103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst