Provider Demographics
NPI:1891013470
Name:TRUTTER, KELLY (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TRUTTER
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 1:2423 CULPEPPER WAY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7833
Mailing Address - Country:US
Mailing Address - Phone:916-752-3961
Mailing Address - Fax:916-543-6470
Practice Address - Street 1:5221 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5190
Practice Address - Country:US
Practice Address - Phone:916-752-3961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst