Healthcare Provider Details

I. General information

NPI: 1477467660
Provider Name (Legal Business Name): MERRICK ELLIS RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 S MAIN ST
GROVE OK
74344-5368
US

IV. Provider business mailing address

553 S COLCORD AVE
COLCORD OK
74338-1740
US

V. Phone/Fax

Practice location:
  • Phone: 918-557-4496
  • Fax:
Mailing address:
  • Phone: 479-228-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: