Provider Demographics
NPI:1457803892
Name:MACHULIS, KELSEY (BCBA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MACHULIS
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 1:3720 W SUNGLADE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-1136
Mailing Address - Country:US
Mailing Address - Phone:708-528-1861
Mailing Address - Fax:
Practice Address - Street 1:1 S CHURCH AVE STE 1200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-1601
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-16-23572103K00000X
AZBEH000390103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBEH000390OtherAZ BOARD OF PSYCHOLOGY EXAMINERS