Provider Demographics
NPI:1336854744
Name:ELLIS, TE'AMBER LATRICE (RBT)
Entity Type:Individual
Prefix:
First Name:TE'AMBER
Middle Name:LATRICE
Last Name:ELLIS
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 1:5522 LONE STAR PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6719
Mailing Address - Country:US
Mailing Address - Phone:210-670-8028
Mailing Address - Fax:
Practice Address - Street 1:4927 LAKE RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3066
Practice Address - Country:US
Practice Address - Phone:214-251-8758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician