=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063807402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY B. MUNSELL M.ED., BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2015
-----------------------------------------------------
Last Update Date | 02/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21929 HIGHLAND KNOLLS DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-5873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-342-5841
-----------------------------------------------------
Fax | 605-271-3956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2804 E 26TH ST STE 1
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57103-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-271-2690
-----------------------------------------------------
Fax | 52-713-9566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-14-16859
-----------------------------------------------------
License Number State |
-----------------------------------------------------