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General NPI Number Information
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NPI Number | 1073903266
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Entity Type | Individual
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Provider Name | COURTNEY KELLY BCBA
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Gender | Female
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Dates
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Enumeration Date | 01/27/2015
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Last Update Date | 07/08/2019
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Provider Practice Location Address
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Address Line | 7 E CREEK CIR
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City | GUILFORD
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State | CT
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Zip | 06437-2821
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Country | US
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Telephone | 203-779-9074
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Fax |
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Provider Business Mailing Address
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Address Line | 18 PARDEE PL
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City | MADISON
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State | CT
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Zip | 06443-2207
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Country | US
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Telephone | 203-779-9074
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 11416535
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License Number State | CT
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