Healthcare Provider Details

I. General information

NPI: 1407219165
Provider Name (Legal Business Name): CHRISTOPHER DEGRAFFENRIED KEENAN JR. BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 04/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 BLANDING ST
COLUMBIA SC
29201-2906
US

IV. Provider business mailing address

PO BOX 7514
COLUMBIA SC
29202-7514
US

V. Phone/Fax

Practice location:
  • Phone: 803-929-0011
  • Fax: 803-569-1054
Mailing address:
  • Phone: 803-929-0011
  • Fax: 803-569-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-21983
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: