Provider Demographics
NPI:1710396619
Name:UDO, KERRY (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:UDO
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15373 INNOVATION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3415
Mailing Address - Country:US
Mailing Address - Phone:858-699-7579
Mailing Address - Fax:
Practice Address - Street 1:15373 INNOVATION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3415
Practice Address - Country:US
Practice Address - Phone:858-699-7579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-13559103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst