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NPI Code Detail

MEDICARE: KERA JO ELLISON

MEDICARE: KERA JO ELLISON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianAL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1RBT-20-146872OTHERALRBT-20-146872

General Provider Information

NPI Number : 1184210890
Entity Type Code : Individual
Provider Name (Legal Business Name) : KERA JO ELLISON
Provider Business Mailing Address
First Line : 1018 S BRUNDIDGE ST
Second Line :
City : TROY
State : AL
Zip : 36081-3148
Country : US
Telephone Number : 334-792-5020
Fax Number :
Provider Business Practice Location Address
First Line : 1018 S BRUNDIDGE ST
Second Line :
City : TROY
State : AL
Zip : 36081-3148
Country : US
Telephone Number : 334-792-5020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/16/2020
Last Update Date : 12/16/2020

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Directions to “ KERA JO ELLISON ” Practice Location

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