Provider Demographics
NPI:1114443801
Name:MOLLES, KEELY (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:MOLLES
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ATLANTIC AVE # SET101
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1189
Mailing Address - Country:US
Mailing Address - Phone:510-268-8120
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE # SET101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1189
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-25600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst