Healthcare Provider Details

I. General information

NPI: 1093295032
Provider Name (Legal Business Name): KAITLYN BRADSHAW BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 10TH ST STE C
ROCK VALLEY IA
51247-1511
US

IV. Provider business mailing address

1105 W RUSSELL ST
SIOUX FALLS SD
57104-1322
US

V. Phone/Fax

Practice location:
  • Phone: 712-454-3484
  • Fax:
Mailing address:
  • Phone: 605-271-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-45677
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57026
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: