Provider Demographics
NPI:1467074765
Name:DENEVE, KELLY (MED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:DENEVE
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 1:1202 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1223
Mailing Address - Country:US
Mailing Address - Phone:574-520-3821
Mailing Address - Fax:
Practice Address - Street 1:53779 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1576
Practice Address - Country:US
Practice Address - Phone:219-359-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-42018103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst