Provider Demographics
NPI:1831668185
Name:WELLS, KATY (BCBA)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:WELLS
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 1:1575 ALLOUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5639
Mailing Address - Country:US
Mailing Address - Phone:208-918-4103
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-8370
Practice Address - Country:US
Practice Address - Phone:208-918-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-1935287103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst