Provider Demographics
NPI:1639706765
Name:BAILEY, KEITH EVERETT (BCBA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EVERETT
Last Name:BAILEY
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 COTY DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2094
Mailing Address - Country:US
Mailing Address - Phone:318-209-4033
Mailing Address - Fax:318-209-4043
Practice Address - Street 1:2001 W COURT ST STE A
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-4601
Practice Address - Country:US
Practice Address - Phone:318-209-4033
Practice Address - Fax:318-209-4043
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL-435OtherLOUISIANA BEHAVIOR ANALYST CERTIFICATION BOARD