Provider Demographics
NPI:1619536992
Name:SWANSON, KELSEY (BCBA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SWANSON
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 1:99 AUDREY CIR
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-8950
Mailing Address - Country:US
Mailing Address - Phone:860-930-3809
Mailing Address - Fax:
Practice Address - Street 1:99 AUDREY CIR
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424-8950
Practice Address - Country:US
Practice Address - Phone:860-930-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-18-33830103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty