Provider Demographics
NPI:1790456937
Name:KALEIDOSCOPE BEHAVIOR SERVICES
Entity Type:Organization
Organization Name:KALEIDOSCOPE BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:985-413-8127
Mailing Address - Street 1:4908 RANDEE CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-2054
Mailing Address - Country:US
Mailing Address - Phone:985-413-8127
Mailing Address - Fax:
Practice Address - Street 1:4908 RANDEE CIR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-2054
Practice Address - Country:US
Practice Address - Phone:985-413-8127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821542473OtherNPI1