MEDICARE: TRACI KELLY M.ED, BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-21-47100	TX

General Provider Information

NPI Number	:	1003406554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI KELLY M.ED, BCBA

Provider Business Mailing Address
First Line	:	9636 LEA SHORE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3225
Country	:	US
Telephone Number	:	817-682-0163
Fax Number	:

Provider Business Practice Location Address
First Line	:	9636 LEA SHORE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3225
Country	:	US
Telephone Number	:	817-682-0163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2021
Last Update Date	:	01/19/2021

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