MEDICARE: KELLEY ANNE DODSON M.ED, 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	:	1679040836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY ANNE DODSON M.ED, BCBA

Provider Business Mailing Address
First Line	:	7161 W POTOMAC DR
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-9148
Country	:	US
Telephone Number	:	208-629-8225
Fax Number	:

Provider Business Practice Location Address
First Line	:	7161 W POTOMAC DR
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-9148
Country	:	US
Telephone Number	:	208-629-8225
Fax Number	:

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

Provider Enumeration Date	:	10/25/2018
Last Update Date	:	10/25/2018

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