Healthcare Provider Details

I. General information

NPI: 1780317164
Provider Name (Legal Business Name): ELLEN MAE KEHOE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 3RD AVE STE B8
CHULA VISTA CA
91910-3990
US

IV. Provider business mailing address

PO BOX 33568
SAN DIEGO CA
92163-3568
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax: 619-374-7134
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-78802
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-24-15209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: