Healthcare Provider Details

I. General information

NPI: 1124507082
Provider Name (Legal Business Name): KELSEY SHAY HLADIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 08/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 HUKILIKE ST
KAHULUI HI
96732-2999
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367-7807
US

V. Phone/Fax

Practice location:
  • Phone: 808-868-5662
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberS112170027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: