Basic Information
| Provider Information | |||||||||
| NPI: | 1104572221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGILL | ||||||||
| FirstName: | KEELY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MA-BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 CONGRESSIONAL BLVD STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460325632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172492242 | ||||||||
| FaxNumber: | 8442896798 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 N CANTERBURY CT | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474041500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172492242 | ||||||||
| FaxNumber: | 8442896798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2022 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-22-58247 | IN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.