Provider Demographics
NPI:1790450823
Name:PENNICK, ADRIAN ELISSE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:ELISSE
Last Name:PENNICK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 N STATE ROAD 7 STE 300
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5867
Mailing Address - Country:US
Mailing Address - Phone:561-323-6593
Mailing Address - Fax:
Practice Address - Street 1:101 E PARK BLVD STE 600
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-8818
Practice Address - Country:US
Practice Address - Phone:561-323-6593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6632103K00000X
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician