=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679134043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDD'S KIDS ABA THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2019
-----------------------------------------------------
Last Update Date | 06/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20502 PROVIDENCE POINT DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77449-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-326-9290
-----------------------------------------------------
Fax | 832-301-4998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20502 PROVIDENCE POINT DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77449-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-326-9290
-----------------------------------------------------
Fax | 832-301-4998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BCBA/CEO
-----------------------------------------------------
Name | KERA KIDD
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 210-326-9290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------