MEDICARE: MRS. KELLEY N GARDNER-PRINCE BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-05-2597	FL

General Provider Information

NPI Number	:	1013172154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLEY N GARDNER-PRINCE BCBA

Provider Business Mailing Address
First Line	:	6916 W LINEBAUGH AVE
Second Line	:	SUITE 102
City	:	TAMPA
State	:	FL
Zip	:	33625-5800
Country	:	US
Telephone Number	:	813-265-0210
Fax Number	:	813-265-0218

Provider Business Practice Location Address
First Line	:	6916 W LINEBAUGH AVE
Second Line	:	SUITE 102
City	:	TAMPA
State	:	FL
Zip	:	33625-5800
Country	:	US
Telephone Number	:	813-265-0210
Fax Number	:	813-265-0218

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2008
Last Update Date	:	04/29/2009

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