Tristina Marie Ellenburg, MS, BCBA, COBA, LBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-17-26378

Practice address

2147 Newnan Crossing Blvd E
Newnan, GA 30265-2406

Phone

(470) 241-1408

Fax

(317) 520-8200

NPI assigned

Aug 31, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1504137600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1607904000000",
    "number": "1730607698",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3500 DEPAUW BLVD STE 3070",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462686135",
            "telephone_number": "855-324-0885",
            "fax_number": "317-520-8200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2147 NEWNAN CROSSING BLVD E",
            "city": "NEWNAN",
            "state": "GA",
            "postal_code": "302652406",
            "telephone_number": "470-241-1408",
            "fax_number": "317-520-8200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLENBURG",
        "first_name": "TRISTINA",
        "middle_name": "MARIE",
        "credential": "MS, BCBA, COBA, LBA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-08-31",
        "last_updated": "2020-12-14",
        "certification_date": "2020-12-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "KY",
            "license": "267579",
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "OH",
            "license": "COBA.00590",
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": null,
            "license": "1-17-26378",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBA CERTIFICATE",
            "identifier": "1-17-26378",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Behavior Analyst in Newnan, GA
• Providers in Newnan, GA by specialty
• Behavior Analyst in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.