Provider Demographics
NPI:1649914318
Name:ELIS, CHRISTINA IRENE
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:IRENE
Last Name:ELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 GLENCOVE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-8609
Mailing Address - Country:US
Mailing Address - Phone:321-541-5597
Mailing Address - Fax:
Practice Address - Street 1:1550 GLENCOVE AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-8609
Practice Address - Country:US
Practice Address - Phone:321-541-5597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician