Healthcare Provider Details

I. General information

NPI: 1649742677
Provider Name (Legal Business Name): REBECCA M KELLETT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2767 E US HIGHWAY 6
KENDALLVILLE IN
46755-9341
US

IV. Provider business mailing address

2767 E US HIGHWAY 6
KENDALLVILLE IN
46755-9341
US

V. Phone/Fax

Practice location:
  • Phone: 260-336-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-46367
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-41466
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: