Healthcare Provider Details

I. General information

NPI: 1477491330
Provider Name (Legal Business Name): GRACIE ELLIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9802 NICHOLAS ST STE 395
OMAHA NE
68114-2168
US

IV. Provider business mailing address

185 ROUTE 70 STE 302
TOMS RIVER NJ
08755-0911
US

V. Phone/Fax

Practice location:
  • Phone: 732-806-0091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: