Provider Demographics
NPI:1104383637
Name:PHELAN, COLTON SKYLER MCCREADY (BCBA)
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:SKYLER MCCREADY
Last Name:PHELAN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:SKY
Other - Middle Name:
Other - Last Name:MCCREADY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:5862 SANDBURG DR
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-5835
Mailing Address - Country:US
Mailing Address - Phone:239-940-2481
Mailing Address - Fax:
Practice Address - Street 1:5862 SANDBURG DR
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-5835
Practice Address - Country:US
Practice Address - Phone:239-940-2481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-50346103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician