Provider Demographics
NPI:1023511383
Name:KETNER, KELLI (BCBA)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:
Last Name:KETNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:KETNER
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:4400 E EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1353 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1433
Practice Address - Country:US
Practice Address - Phone:317-520-4748
Practice Address - Fax:888-498-5529
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO12043059103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300049688Medicaid