Provider Demographics
NPI:1629587969
Name:STARR, KELLY CARROLL (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CARROLL
Last Name:STARR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CARROLL
Other - Last Name:GERULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:2921 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3707
Mailing Address - Country:US
Mailing Address - Phone:408-893-5515
Mailing Address - Fax:
Practice Address - Street 1:2 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7929
Practice Address - Country:US
Practice Address - Phone:408-893-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-17231103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst