Provider Demographics
NPI:1346701000
Name:KELLY, CAITLIN MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:KELLY
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 1:11412 N 134TH EAST AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4969
Mailing Address - Country:US
Mailing Address - Phone:918-629-6330
Mailing Address - Fax:
Practice Address - Street 1:11412 N 134TH EAST AVE STE C3
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4969
Practice Address - Country:US
Practice Address - Phone:918-376-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst