MEDICARE: KELLI DEWETT MS, 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	1-17-25141	CA

General Provider Information

NPI Number	:	1679005250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI DEWETT MS, BCBA

Provider Business Mailing Address
First Line	:	7210 READING RD APT 622
Second Line	:
City	:	ROSENBERG
State	:	TX
Zip	:	77469-5292
Country	:	US
Telephone Number	:	760-271-2656
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 WILLIAMS TRACE BLVD STE 101
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77478-4443
Country	:	US
Telephone Number	:	895-329-7972
Fax Number	:

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

Provider Enumeration Date	:	04/01/2017
Last Update Date	:	03/25/2021

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