MEDICARE: OLIVIA KATHLEEN ELLIS BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-26-88966	GA

General Provider Information

NPI Number	:	1982547741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA KATHLEEN ELLIS BCBA

Provider Business Mailing Address
First Line	:	314 CHEROKEE RD
Second Line	:
City	:	THOMASTON
State	:	GA
Zip	:	30286-4037
Country	:	US
Telephone Number	:	706-594-0280
Fax Number	:

Provider Business Practice Location Address
First Line	:	14557 US 19 SUITE C
Second Line	:
City	:	GRIFFIN
State	:	GA
Zip	:	30224
Country	:	US
Telephone Number	:	770-468-6941
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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