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NPI Code Detail

MEDICARE: KATHLEEN MARIE KELLY B.C.B.A

MEDICARE: KATHLEEN MARIE KELLY B.C.B.A
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst0-12-4466CA
2103K00000XBehavior Analyst1-12-12621CA

General Provider Information

NPI Number : 1528328432
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHLEEN MARIE KELLY B.C.B.A
Provider Business Mailing Address
First Line : 1031 S CRESCENT HEIGHTS BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90035-2632
Country : US
Telephone Number : 925-324-5494
Fax Number :
Provider Business Practice Location Address
First Line : 1031 S CRESCENT HEIGHTS BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90035-2632
Country : US
Telephone Number : 925-324-5494
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2012
Last Update Date : 07/14/2016

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