Provider Demographics
NPI:1982121935
Name:MOSEMAN, KELLY C (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:MOSEMAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:WIECZOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:3010 N 187TH CT
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N 93RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2697
Practice Address - Country:US
Practice Address - Phone:402-230-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NE1-21-48102103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst