Healthcare Provider Details

I. General information

NPI: 1104321769
Provider Name (Legal Business Name): KAITLYN MICHELLE ANDERSON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 02/11/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1582 N WAGGONER RD STE A
BLACKLICK OH
43004-8669
US

IV. Provider business mailing address

390 UNION BLVD STE 300
LAKEWOOD CO
80228-6514
US

V. Phone/Fax

Practice location:
  • Phone: 614-344-0419
  • Fax:
Mailing address:
  • Phone: 303-989-8169
  • Fax: 303-984-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11831816
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: