Healthcare Provider Details

I. General information

NPI: 1104731769
Provider Name (Legal Business Name): ELIZABETH MELLON BCBA
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: ELIZABETH GARCIA BCBA

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 N ROCKTON AVE
ROCKFORD IL
61103-1526
US

IV. Provider business mailing address

173 AUTUMNWOOD LN
DAVIS JUNCTION IL
61020-9426
US

V. Phone/Fax

Practice location:
  • Phone: 815-985-9591
  • Fax:
Mailing address:
  • Phone: 815-985-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1262841007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: