Healthcare Provider Details

I. General information

NPI: 1639862139
Provider Name (Legal Business Name): HOLLY ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 LONGVIEW DR
JONESBORO AR
72401-5919
US

IV. Provider business mailing address

5625 WILDFLOWER CT
JONESBORO AR
72404-8882
US

V. Phone/Fax

Practice location:
  • Phone: 870-842-3274
  • Fax:
Mailing address:
  • Phone: 870-340-7808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-84897
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-25-16190
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-272646
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: