Provider Demographics
NPI:1356861819
Name:ROBBEN, KELLY (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:ROBBEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 COLLEGE BLVD E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1343
Mailing Address - Country:US
Mailing Address - Phone:850-279-3000
Mailing Address - Fax:850-389-2269
Practice Address - Street 1:9917 W ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3405
Practice Address - Country:US
Practice Address - Phone:850-797-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0177958106E00000X
1-17-27016103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-27016OtherBACB