Healthcare Provider Details

I. General information

NPI: 1669193843
Provider Name (Legal Business Name): TIFFANY KELLY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 INDUSTRIAL DR STE E
SAINT MARYS GA
31558-4436
US

IV. Provider business mailing address

112 CAMBRAY CIR
SAINT MARYS GA
31558-3502
US

V. Phone/Fax

Practice location:
  • Phone: 912-324-5012
  • Fax: 912-576-7075
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA002919
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133005355
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-206597
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: