Provider Demographics
NPI:1649403718
Name:CHIVERS, CARLY JEAN (MS, BCBA, COBA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:CHIVERS
Suffix:
Gender:F
Credentials:MS, BCBA, COBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:317-520-8200
Practice Address - Street 1:703 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150
Practice Address - Country:US
Practice Address - Phone:513-831-2578
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOBA.00497103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-14-17170OtherBCBA CERTIFICATE