MEDICARE: KELLY LYNN KNOWLES

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

General Provider Information

NPI Number	:	1700303187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYNN KNOWLES

Provider Business Mailing Address
First Line	:	2425 CHANNING WAY STE B, PMB 454
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2260
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 CHANNING WAY STE B
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2260
Country	:	US
Telephone Number	:	510-296-5401
Fax Number	:

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

Provider Enumeration Date	:	08/25/2017
Last Update Date	:	09/18/2018

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Directions to “ KELLY LYNN KNOWLES ” Practice Location

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