Provider Demographics
NPI:1023374105
Name:GANSARSKI, KELLY ROBIN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ROBIN
Last Name:GANSARSKI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-9503
Mailing Address - Country:US
Mailing Address - Phone:570-561-9378
Mailing Address - Fax:
Practice Address - Street 1:279 LAUREL DR
Practice Address - Street 2:
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-9503
Practice Address - Country:US
Practice Address - Phone:570-561-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-03-1139103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst