=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326712175
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL KELLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2021
-----------------------------------------------------
Last Update Date | 01/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 SUSSEX AVE
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19963-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-503-3120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17128 WINDWARD BLVD UNIT 201
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19963-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-296-8427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-22-59809
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------