Provider Demographics
NPI:1134679004
Name:KENNEY-LAZAR, MAXWELL (BCBA, LBA)
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:
Last Name:KENNEY-LAZAR
Suffix:
Gender:M
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 HONEYGO CENTER DR
Mailing Address - Street 2:STE 102
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-8963
Mailing Address - Country:US
Mailing Address - Phone:603-986-9991
Mailing Address - Fax:
Practice Address - Street 1:7175 COLUMBIA GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2534
Practice Address - Country:US
Practice Address - Phone:603-986-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA257103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst