=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811356835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLYE NICOLE BAGEON MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 892 S FRONTENAC ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-264-8225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 892 S FRONTENAC ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-264-8225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 369971
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------