Healthcare Provider Details

I. General information

NPI: 1619540432
Provider Name (Legal Business Name): CASSANDRA KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E SHAW AVE STE 190
FRESNO CA
93710-8114
US

IV. Provider business mailing address

5132 N PALM AVE # 303
FRESNO CA
93704-2236
US

V. Phone/Fax

Practice location:
  • Phone: 559-492-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-81665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: