=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396330213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELNOELL BEHAVIOR SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2021
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 535 APPLE ST
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-3524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-221-2434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20232
-----------------------------------------------------
City | SUN VALLEY
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89433-0232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-221-2434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HETAHER NOELL ENABULELE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-221-2434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------