Provider Demographics
NPI:1811369515
Name:LONESTAR, ELIA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:ELIA
Middle Name:
Last Name:LONESTAR
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 US HIGHWAY 12 SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MN
Mailing Address - Zip Code:55390-8500
Mailing Address - Country:US
Mailing Address - Phone:925-698-2903
Mailing Address - Fax:
Practice Address - Street 1:2909 US HIGHWAY 12 SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:MN
Practice Address - Zip Code:55390-8500
Practice Address - Country:US
Practice Address - Phone:925-698-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-26483103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty