Provider Demographics
NPI:1225244767
Name:BOVINO, KATHRYN M (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:BOVINO
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 1:9466 BLACK MOUNTAIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4550
Mailing Address - Country:US
Mailing Address - Phone:858-689-2027
Mailing Address - Fax:858-397-2172
Practice Address - Street 1:9466 BLACK MOUNTAIN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4550
Practice Address - Country:US
Practice Address - Phone:858-689-2027
Practice Address - Fax:858-397-2172
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
222Q00000X
CA1-17-26371103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist