Provider Demographics
NPI:1679019913
Name:BEWLEY, KRISTINA ASHLEE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ASHLEE
Last Name:BEWLEY
Suffix:
Gender:F
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:PO BOX 7606
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33758-7606
Mailing Address - Country:US
Mailing Address - Phone:727-641-0218
Mailing Address - Fax:
Practice Address - Street 1:1258 W BAY DR STE F
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2240
Practice Address - Country:US
Practice Address - Phone:727-641-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-28272103K00000X
FL0-15-6751106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019719700Medicaid