Provider Demographics
NPI:1255008900
Name:KIDNEY, KATELYN (BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:KIDNEY
Suffix:
Gender:F
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-1103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:461 RIVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4349
Practice Address - Country:US
Practice Address - Phone:978-654-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3655-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3655-MH-B1OtherBOARD OF ALLIED MENTAL HEALTH AND HUMAN SERVICE PROFESSIONALS