Basic Information
| Provider Information | |||||||||
| NPI: | 1730565375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELLIS | ||||||||
| FirstName: | GABRIELLA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 W 1124 N APT 1 | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843416851 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 630 S RANCHO DR STE A | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029989505 | ||||||||
| FaxNumber: | 7025277939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2015 | ||||||||
| LastUpdateDate: | 02/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-15-05675 | NV | Y |
ID Information
| ID | Type | State | Issuer | Description | 1730565375 | 05 | NV | MEDICAID | RBT-15-05675 | 01 | NV | BEHAVIOR TECHNICIAN REGISTRY | OTHER |