1538659503 NPI number — BAILEY BLAKE KADLEC M.ED., BCBA-LBA

Table of content: BAILEY BLAKE KADLEC M.ED., BCBA-LBA (NPI 1538659503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538659503 NPI number — BAILEY BLAKE KADLEC M.ED., BCBA-LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KADLEC
Provider First Name:
BAILEY
Provider Middle Name:
BLAKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED., BCBA-LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538659503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 N. DOBSON RD
Provider Second Line Business Mailing Address:
STE F-2
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85224-9611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-722-1300
Provider Business Mailing Address Fax Number:
480-422-3824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 N DOBSON RD STE F-2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224-9611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-722-1300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  BA-320 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: BEH-000320 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 399869 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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