MEDICARE: KAILI JADE YOUNG 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	1-17-27238	CO

General Provider Information

NPI Number	:	1023797610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAILI JADE YOUNG BCBA

Provider Business Mailing Address
First Line	:	425 ORILLA DEL LAGO
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-8921
Country	:	US
Telephone Number	:	970-980-0663
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 ORILLA DEL LAGO
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-8921
Country	:	US
Telephone Number	:	970-980-0663
Fax Number	:

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

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	07/12/2023

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