Healthcare Provider Details

I. General information

NPI: 1134602162
Provider Name (Legal Business Name): KELLY H CHANG BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 PAINTER AVE STE 200
WHITTIER CA
90602-3168
US

IV. Provider business mailing address

4505 W 5TH ST APT 14
LOS ANGELES CA
90020-4707
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-6600
  • Fax: 562-698-6613
Mailing address:
  • Phone: 213-500-1941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-29603
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number21953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: