Provider Demographics
NPI:1508756230
Name:HAZEL GRACE CENTER FOR AUTISM
Entity type:Organization
Organization Name:HAZEL GRACE CENTER FOR AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ELLICKSON-ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:920-224-5048
Mailing Address - Street 1:106 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1352
Mailing Address - Country:US
Mailing Address - Phone:920-224-5048
Mailing Address - Fax:
Practice Address - Street 1:106 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1352
Practice Address - Country:US
Practice Address - Phone:920-224-5048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty