Provider Demographics
NPI:1477101954
Name:KEITH, KRISTINA (BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:KEITH
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 1:321 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1750
Mailing Address - Country:US
Mailing Address - Phone:508-478-0207
Mailing Address - Fax:508-634-6984
Practice Address - Street 1:5330 YACHT HAVEN GRANDE BLDG J
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-5028
Practice Address - Country:US
Practice Address - Phone:340-202-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
AL2024-024103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist