Provider Demographics
NPI:1801402037
Name:GIVAN, KELLY (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GIVAN
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 796
Mailing Address - Street 2:
Mailing Address - City:AVILA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93424-0796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 1ST ST
Practice Address - Street 2:
Practice Address - City:AVILA BEACH
Practice Address - State:CA
Practice Address - Zip Code:93424-3500
Practice Address - Country:US
Practice Address - Phone:805-202-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-20-44534103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst