Provider Demographics
NPI:1205170313
Name:GLISSON KELLER, MARY JANE (EDS, BCBA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:GLISSON KELLER
Suffix:
Gender:F
Credentials:EDS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 NEAL LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-6235
Mailing Address - Country:US
Mailing Address - Phone:618-527-0736
Mailing Address - Fax:
Practice Address - Street 1:1535 NEAL LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6235
Practice Address - Country:US
Practice Address - Phone:618-527-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst