Provider Demographics
NPI:1568030963
Name:KELLY, KATHRYN M (BCBA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:M
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:3925 MIDLANDS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2575
Mailing Address - Country:US
Mailing Address - Phone:757-585-3216
Mailing Address - Fax:757-561-2541
Practice Address - Street 1:3925 MIDLANDS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2575
Practice Address - Country:US
Practice Address - Phone:757-585-3216
Practice Address - Fax:757-561-2541
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0133002790103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician