MEDICARE: KAITLYN MICHELLE ANDERSON 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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	11831816	OH

General Provider Information

NPI Number	:	1104321769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN MICHELLE ANDERSON BCBA

Provider Business Mailing Address
First Line	:	390 UNION BLVD STE 300
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-6514
Country	:	US
Telephone Number	:	303-989-8169
Fax Number	:	303-984-4366

Provider Business Practice Location Address
First Line	:	1582 N WAGGONER RD STE A
Second Line	:
City	:	BLACKLICK
State	:	OH
Zip	:	43004-8669
Country	:	US
Telephone Number	:	614-344-0419
Fax Number	:

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

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	02/11/2025

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