Provider Demographics
NPI:1508526120
Name:GOLDBERGER, KELLYN ANN (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:ANN
Last Name:GOLDBERGER
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 MAIN ST APT C4
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2952
Mailing Address - Country:US
Mailing Address - Phone:860-987-7766
Mailing Address - Fax:
Practice Address - Street 1:46 W AVON RD STE 202
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3679
Practice Address - Country:US
Practice Address - Phone:860-673-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1076103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst