Provider Demographics
NPI:1447723523
Name:ANDERSON, KELLIE ANN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2790
Mailing Address - Country:US
Mailing Address - Phone:516-578-2236
Mailing Address - Fax:
Practice Address - Street 1:1400 DIXON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2790
Practice Address - Country:US
Practice Address - Phone:516-578-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-18-32942103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst