=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467307058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIDDHARTH NELLURI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2026
-----------------------------------------------------
Last Update Date | 02/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 773 BANDIT TRL
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-0111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-673-5278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 841 RANCHLAND RD
-----------------------------------------------------
City | JUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76247-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-750-7041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-25-433011
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------