Provider Demographics
NPI:1104167949
Name:MARCELLIS, BROOKE (BCBA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MARCELLIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9059 INDIGO LK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1673
Mailing Address - Country:US
Mailing Address - Phone:715-313-0940
Mailing Address - Fax:
Practice Address - Street 1:3229 CASTLEDALE DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3901
Practice Address - Country:US
Practice Address - Phone:210-685-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-13346103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst