Provider Demographics
NPI:1366977910
Name:PHILLIPS-PAYNE, CHELSEA LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LYNN
Last Name:PHILLIPS-PAYNE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:
Other - Last Name:TRUESDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:903 LAKE LILY DR APT A122
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7606
Mailing Address - Country:US
Mailing Address - Phone:502-612-3474
Mailing Address - Fax:
Practice Address - Street 1:903 LAKE LILY DR APT A122
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:502-612-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-17-27384103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019557900Medicaid