Provider Demographics
NPI:1346762523
Name:BERNARD, KELLY LYNN (MED, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BERNARD
Suffix:
Gender:F
Credentials:MED, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-915-7729
Mailing Address - Fax:
Practice Address - Street 1:7326 LITTLE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-5518
Practice Address - Country:US
Practice Address - Phone:727-364-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2032-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty