Provider Demographics
NPI:1316446958
Name:JOHNSON, KILEY (MA, BCBA)
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:JOHNSON
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 1:1555 SE DELAWARE AVE STE O
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-4011
Mailing Address - Country:US
Mailing Address - Phone:515-261-2402
Mailing Address - Fax:
Practice Address - Street 1:1555 SE DELAWARE AVE STE O
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4011
Practice Address - Country:US
Practice Address - Phone:515-261-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IARBT-18-49382106S00000X
IA1-21-48268103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA822272447OtherPRIVATE INSURANCE AND PRIVATE PAY