Healthcare Provider Details

I. General information

NPI: 1023955283
Provider Name (Legal Business Name): KILEY MELLOTT RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16620 N 40TH ST BLDG C
PHOENIX AZ
85032-3348
US

IV. Provider business mailing address

2246 W TONOPAH DR
PHOENIX AZ
85027-3427
US

V. Phone/Fax

Practice location:
  • Phone: 602-649-0149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-533786
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: