MEDICARE: CLARA KENNY BCBA

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
1	103K00000X	Behavior Analyst	1-13-13863

General Provider Information

NPI Number	:	1831567882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARA KENNY BCBA

Provider Business Mailing Address
First Line	:	2200 WILSON BLVD STE 102-190
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-3397
Country	:	US
Telephone Number	:	202-813-9088
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 WILSON BLVD STE 102-190
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-3397
Country	:	US
Telephone Number	:	202-813-9088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	09/08/2015

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