Provider Demographics
NPI:1205335171
Name:SMITH, KELLY J (BCBA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:986 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8818
Mailing Address - Country:US
Mailing Address - Phone:920-544-4970
Mailing Address - Fax:
Practice Address - Street 1:986 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-8818
Practice Address - Country:US
Practice Address - Phone:920-544-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI213-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst