Provider Demographics
NPI:1730553744
Name:PHELPS, KELLEY (BCBA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:PHELPS
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 1:5215 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5708
Mailing Address - Country:US
Mailing Address - Phone:850-270-0640
Mailing Address - Fax:850-564-1399
Practice Address - Street 1:5215 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5708
Practice Address - Country:US
Practice Address - Phone:850-270-0640
Practice Address - Fax:850-564-1399
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst