Provider Demographics
NPI:1093232183
Name:HYDE, KELLI MARIE (MSW, BCBA, COBA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:HYDE
Suffix:
Gender:F
Credentials:MSW, BCBA, COBA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:MEINERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-454-9759
Practice Address - Street 1:1255 KEMPER MEADOW DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-1633
Practice Address - Country:US
Practice Address - Phone:513-294-1522
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-16-22259103K00000X
OHCOBA338103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-16-22259OtherBCBA CERTIFICATE
OH1-16-22259OtherBACB