Provider Demographics
NPI:1689218612
Name:ROSS, KYLIE (MSED LBS BCBA)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:MSED LBS BCBA
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:
Other - Last Name:BROFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED LBS BCBA
Mailing Address - Street 1:630 FITZWATERTOWN RD STE A2
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1928
Mailing Address - Country:US
Mailing Address - Phone:877-933-9932
Mailing Address - Fax:
Practice Address - Street 1:630 FITZWATERTOWN RD STE A2
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1928
Practice Address - Country:US
Practice Address - Phone:877-933-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-12446106E00000X
1-22-58270103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABCBAMedicaid