Provider Demographics
NPI:1245997535
Name:PHILLIPS, KELLY WILLARD (BCBA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:WILLARD
Last Name:PHILLIPS
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 1:2580 17TH ST UNIT 211
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-6411
Mailing Address - Country:US
Mailing Address - Phone:650-799-3931
Mailing Address - Fax:
Practice Address - Street 1:2580 17TH ST UNIT 211
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-6411
Practice Address - Country:US
Practice Address - Phone:650-799-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNBACB454147103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst