Provider Demographics
NPI:1932645678
Name:MURRAY, ELITCA
Entity Type:Individual
Prefix:
First Name:ELITCA
Middle Name:
Last Name:MURRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELITCA
Other - Middle Name:
Other - Last Name:MAVRODIEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA, LBA
Mailing Address - Street 1:2125 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1855 WICKHAM ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1163
Practice Address - Country:US
Practice Address - Phone:248-797-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-24224103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7401000639OtherLICENSED BEHAVIOR ANALYST
1-16-24224OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD