Healthcare Provider Details

I. General information

NPI: 1104299734
Provider Name (Legal Business Name): KEVIN VAN LAEKEN BCBA, LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PARKWAY SUITE 320 #273
SANTA CLARA CA
95054
US

IV. Provider business mailing address

5201 GREAT AMERICA PARKWAY SUITE 320 #273
SANTA CLARA CA
95054
US

V. Phone/Fax

Practice location:
  • Phone: 530-227-2883
  • Fax:
Mailing address:
  • Phone: 530-227-2883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3635
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number3635
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP3635
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: