Provider Demographics
NPI:1841836863
Name:KINCAID, KILEY
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:KINCAID
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4676
Mailing Address - Country:US
Mailing Address - Phone:844-263-1613
Mailing Address - Fax:
Practice Address - Street 1:4921 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4676
Practice Address - Country:US
Practice Address - Phone:844-263-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60936938106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician