Healthcare Provider Details

I. General information

NPI: 1568334167
Provider Name (Legal Business Name): KELLY SUDOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 LIME ST
RIVERSIDE CA
92501-2971
US

IV. Provider business mailing address

3600 LIME ST
RIVERSIDE CA
92501-2971
US

V. Phone/Fax

Practice location:
  • Phone: 951-813-4034
  • Fax:
Mailing address:
  • Phone: 951-813-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-474595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: