Provider Demographics
NPI:1295223337
Name:BEATTY, MICHELLE VICTORIA (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VICTORIA
Last Name:BEATTY
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 1:1824 TOUBY PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2573
Mailing Address - Country:US
Mailing Address - Phone:765-628-7400
Mailing Address - Fax:
Practice Address - Street 1:2301 W BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-1849
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-13078106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician