MEDICARE: KILEY ROGGENKAMP 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	1-19-38090	TX

General Provider Information

NPI Number	:	1467093450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KILEY ROGGENKAMP M.ED, BCBA

Provider Business Mailing Address
First Line	:	2828 WOODSIDE ST APT 3118
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-3090
Country	:	US
Telephone Number	:	214-675-4539
Fax Number	:

Provider Business Practice Location Address
First Line	:	4235 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-2691
Country	:	US
Telephone Number	:	469-906-6372
Fax Number	:

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

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	11/27/2023

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