Provider Demographics
NPI:1679155964
Name:LY, ELLEN (MS, BCBA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8225 SIERRA BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4049
Mailing Address - Country:US
Mailing Address - Phone:626-216-8111
Mailing Address - Fax:
Practice Address - Street 1:1274 CENTER COURT DR STE 211
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3668
Practice Address - Country:US
Practice Address - Phone:626-339-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-49359103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst