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NPI Code Detail

MEDICARE: KELLY TRUTTER BCBA

MEDICARE: KELLY TRUTTER 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1891013470
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY TRUTTER BCBA
Provider Business Mailing Address
First Line : 2423 CULPEPPER WAY
Second Line :
City : LINCOLN
State : CA
Zip : 95648-7833
Country : US
Telephone Number : 916-752-3961
Fax Number : 916-543-6470
Provider Business Practice Location Address
First Line : 5221 6TH STREET FRONTAGE RD E
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62703-5190
Country : US
Telephone Number : 916-752-3961
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/06/2010
Last Update Date : 02/24/2021

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