Provider Demographics
NPI:1104572221
Name:MAGILL, KEELY NICOLE (MA-BCBA)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:NICOLE
Last Name:MAGILL
Suffix:
Gender:F
Credentials:MA-BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CONGRESSIONAL BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5632
Mailing Address - Country:US
Mailing Address - Phone:317-249-2242
Mailing Address - Fax:844-289-6798
Practice Address - Street 1:3101 N CANTERBURY CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-1500
Practice Address - Country:US
Practice Address - Phone:317-249-2242
Practice Address - Fax:844-289-6798
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-22-58247103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst