Healthcare Provider Details

I. General information

NPI: 1376034900
Provider Name (Legal Business Name): BENJAMIN KWONG BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 THE ALAMEDA
SAN JOSE CA
95126
US

IV. Provider business mailing address

1285 KOI TER
FREMONT CA
94536-3208
US

V. Phone/Fax

Practice location:
  • Phone: 510-679-3545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: