Provider Demographics
NPI:1417464249
Name:PEGRAM, PRINCESS KNIGHT (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:KNIGHT
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 RUFFIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1893
Mailing Address - Country:US
Mailing Address - Phone:619-297-4300
Mailing Address - Fax:
Practice Address - Street 1:98-2009 KAAHUMANU ST APT J
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-1896
Practice Address - Country:US
Practice Address - Phone:808-452-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HIBA-717103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician