Provider Demographics
NPI:1598993099
Name:BYNUM, KELLIE (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BYNUM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-351-6904
Mailing Address - Fax:602-266-9025
Practice Address - Street 1:11221 N 28TH DR BLDG E
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5615
Practice Address - Country:US
Practice Address - Phone:602-997-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000080103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst