Provider Demographics
NPI:1215544481
Name:DOMBROSKY, KYLIE RAE (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:RAE
Last Name:DOMBROSKY
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:RAE
Other - Last Name:DOMBROSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS, RBT
Mailing Address - Street 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:502-805-1511
Practice Address - Street 1:3761 JOHNSON HALL DR
Practice Address - Street 2:
Practice Address - City:MASONIC HOME
Practice Address - State:KY
Practice Address - Zip Code:40041-9998
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:502-805-1511
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
KYRBT-19-99776106S00000X
KY271493103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-50514OtherBCBA CERTIFICATE