Provider Demographics
NPI:1790450823
Name:PENNICK, ADRIAN ELISSE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:ELISSE
Last Name:PENNICK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 PREMIER DR STE 234
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 PREMIER DR STE 234
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2693
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
TX6632103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician