Healthcare Provider Details

I. General information

NPI: 1023580065
Provider Name (Legal Business Name): KELSEY GRACE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date: 02/21/2025
Reactivation Date: 03/25/2025

III. Provider practice location address

1055 SOUTH ST
WHEATLAND WY
82201-2949
US

IV. Provider business mailing address

225 CEDAR HILL ST STE 200
MARLBOROUGH MA
01752-5900
US

V. Phone/Fax

Practice location:
  • Phone: 855-883-8740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: