Provider Demographics
NPI:1245579374
Name:KELLY MCKINNON & ASSOCIATES, INC.
Entity Type:Organization
Organization Name:KELLY MCKINNON & ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:949-481-7630
Mailing Address - Street 1:27452 CALLE ARROYO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2748
Mailing Address - Country:US
Mailing Address - Phone:949-481-7630
Mailing Address - Fax:949-481-7931
Practice Address - Street 1:27452 CALLE ARROYO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2748
Practice Address - Country:US
Practice Address - Phone:949-481-7630
Practice Address - Fax:949-481-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty