Healthcare Provider Details

I. General information

NPI: 1134611098
Provider Name (Legal Business Name): LORA KELLY MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

IV. Provider business mailing address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

V. Phone/Fax

Practice location:
  • Phone: 773-644-7787
  • Fax:
Mailing address:
  • Phone: 773-644-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57432
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-46444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: