Provider Demographics
NPI:1962144162
Name:ELLIS, ROCHELLE KRISTIN
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:KRISTIN
Last Name:ELLIS
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 1:10508 MEDFORD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-0038
Mailing Address - Country:US
Mailing Address - Phone:540-915-5496
Mailing Address - Fax:
Practice Address - Street 1:10508 MEDFORD LAKE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-0038
Practice Address - Country:US
Practice Address - Phone:540-915-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician