Healthcare Provider Details

I. General information

NPI: 1730721515
Provider Name (Legal Business Name): KELLY MARIE KUYLEN BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2019
Last Update Date: 10/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 LAUREL RD
EAST NORTHPORT NY
11731-1118
US

IV. Provider business mailing address

169 WANSER AVE
INWOOD NY
11096-2114
US

V. Phone/Fax

Practice location:
  • Phone: 305-788-9744
  • Fax:
Mailing address:
  • Phone: 305-788-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0014661
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: