Healthcare Provider Details

I. General information

NPI: 1801559729
Provider Name (Legal Business Name): KELLI SUE MATHENY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 SCOTT ST
COUNCIL BLUFFS IA
51503-0753
US

IV. Provider business mailing address

207 SCOTT ST
COUNCIL BLUFFS IA
51503-0753
US

V. Phone/Fax

Practice location:
  • Phone: 402-676-2069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-01526
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: