MEDICARE: COURTNEY KELLY BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1255902433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY KELLY BCBA

Provider Business Mailing Address
First Line	:	490 FOX TRAIL DR
Second Line	:
City	:	BATAVIA
State	:	IL
Zip	:	60510-8643
Country	:	US
Telephone Number	:	630-450-6603
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 DEAN ST STE 750
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60175-4835
Country	:	US
Telephone Number	:	630-286-0026
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	11/14/2024

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