Provider Demographics
NPI:1346941192
Name:KELLY, KRISTEN (RBT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 BON SECOURS PKWY UNIT A
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7818
Mailing Address - Country:US
Mailing Address - Phone:804-972-1650
Mailing Address - Fax:
Practice Address - Street 1:4334 BON SECOURS PKWY UNIT A
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7818
Practice Address - Country:US
Practice Address - Phone:804-972-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician