Healthcare Provider Details

I. General information

NPI: 1295223337
Provider Name (Legal Business Name): MICHELLE VICTORIA BEATTY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W BRADLEY AVE
CHAMPAIGN IL
61821-1849
US

IV. Provider business mailing address

1824 TOUBY PIKE STE B
KOKOMO IN
46901-2573
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-4313
  • Fax:
Mailing address:
  • Phone: 765-628-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number16-13078
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: