Provider Demographics
NPI:1326419672
Name:BRADY, KRISTINE TAYLOR (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:TAYLOR
Last Name:BRADY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2447 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 111
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2714
Mailing Address - Country:US
Mailing Address - Phone:424-672-6700
Mailing Address - Fax:424-672-6819
Practice Address - Street 1:2447 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 111
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2714
Practice Address - Country:US
Practice Address - Phone:424-672-6700
Practice Address - Fax:424-672-6819
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11520128103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst