Provider Demographics
NPI:1679040836
Name:DODSON, KELLEY ANNE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:DODSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7161 W POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9148
Mailing Address - Country:US
Mailing Address - Phone:208-629-8225
Mailing Address - Fax:
Practice Address - Street 1:7161 W POTOMAC DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9148
Practice Address - Country:US
Practice Address - Phone:208-629-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst