=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760859656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE KERSKA, BCBA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2015
-----------------------------------------------------
Last Update Date | 01/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7220 W JEFFERSON AVE 401
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80235-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-531-0804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7220 W JEFFERSON AVE 401
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80235-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-531-0804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELLE KERSKA
-----------------------------------------------------
Credential | LCSW, BCBA
-----------------------------------------------------
Telephone | 858-531-0804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1073382
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------