1174078935 NPI number — MRS. ALICIA NICOLE ENNIS M.A., BCBA

Table of content: MRS. ALICIA NICOLE ENNIS M.A., BCBA (NPI 1174078935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174078935 NPI number — MRS. ALICIA NICOLE ENNIS M.A., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENNIS
Provider First Name:
ALICIA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174078935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32100 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 185
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-712-4266
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32100 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 185
Provider Business Practice Location Address City Name:
BINGHAM FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-712-4266
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 247200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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