Provider Demographics
NPI:1154905792
Name:DICAPRIO, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:DICAPRIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 JACKSON ST NE APT 7408
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-7907
Mailing Address - Country:US
Mailing Address - Phone:518-796-9549
Mailing Address - Fax:
Practice Address - Street 1:690 VILLAGE TRCE NE BLDG 21
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-1513
Practice Address - Country:US
Practice Address - Phone:770-609-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-20-118222106S00000X
GA1-24-70532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician