Provider Demographics
NPI:1982029443
Name:MAYO, ELLEN NICOLE-BOONE (BCABA, LABA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:NICOLE-BOONE
Last Name:MAYO
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223
Mailing Address - Country:US
Mailing Address - Phone:410-253-0010
Mailing Address - Fax:804-716-7186
Practice Address - Street 1:5500 CHAMBERLAYNE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2207
Practice Address - Country:US
Practice Address - Phone:410-253-0010
Practice Address - Fax:804-716-7186
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000033103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst