Provider Demographics
NPI:1679902118
Name:KELLY, AMANDA DYMPNA (DPSYCHBAT, BCBA-D)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:DYMPNA
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPSYCHBAT, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2122
Mailing Address - Country:US
Mailing Address - Phone:303-505-0897
Mailing Address - Fax:
Practice Address - Street 1:2695 S JERSEY ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6321
Practice Address - Country:US
Practice Address - Phone:303-759-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1-12-10494103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst