Provider Demographics
NPI:1306133897
Name:SANDELS, KELY ANN (MS, BCBA)
Entity type:Individual
Prefix:
First Name:KELY
Middle Name:ANN
Last Name:SANDELS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10313 ABOITE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5435
Mailing Address - Country:US
Mailing Address - Phone:260-705-8088
Mailing Address - Fax:
Practice Address - Street 1:10313 ABOITE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5435
Practice Address - Country:US
Practice Address - Phone:260-705-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-11-9004103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst