Healthcare Provider Details

I. General information

NPI: 1790522613
Provider Name (Legal Business Name): BEHAVIORAL DYNAMICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 RAVEN VIEW RD.
FORT COLLINS CO
80521
US

IV. Provider business mailing address

2519 S SHIELDS ST STE 1K #567
FORT COLLINS CO
80526-1855
US

V. Phone/Fax

Practice location:
  • Phone: 402-916-0138
  • Fax:
Mailing address:
  • Phone: 402-916-0138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA JO WELLENDORF
Title or Position: CO-OWNER
Credential: M.S., BCBA
Phone: 402-916-0138