Provider Demographics
NPI:1881185536
Name:PHILLIPS, KELLY (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SCHOLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4103 CASTELL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2100
Mailing Address - Country:US
Mailing Address - Phone:765-730-3691
Mailing Address - Fax:
Practice Address - Street 1:3030 LAKE AVE STE 20
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-420-9332
Practice Address - Fax:866-446-0198
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-31563103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst