Provider Demographics
NPI:1972004760
Name:LISTON, KENNAN JAY (BCBA)
Entity Type:Individual
Prefix:
First Name:KENNAN
Middle Name:JAY
Last Name:LISTON
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 1:2035 SW 75TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-3425
Mailing Address - Country:US
Mailing Address - Phone:352-332-8588
Mailing Address - Fax:
Practice Address - Street 1:2035 SW 75TH ST STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-3425
Practice Address - Country:US
Practice Address - Phone:352-332-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSMedicaid