Basic Information
| Provider Information | |||||||||
| NPI: | 1033674965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THURMAN | ||||||||
| FirstName: | KELSIE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA, BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2740 SAINT ANDREWS DR | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371286684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 820 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-19-76901 | IA | N |
ID Information
| ID | Type | State | Issuer | Description | Q070622 | 05 | TN | MEDICAID |