Provider Demographics
NPI:1013172154
Name:GARDNER-PRINCE, KELLEY N (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:N
Last Name:GARDNER-PRINCE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:N
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:6916 W LINEBAUGH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-5800
Mailing Address - Country:US
Mailing Address - Phone:813-265-0210
Mailing Address - Fax:813-265-0218
Practice Address - Street 1:6916 W LINEBAUGH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5800
Practice Address - Country:US
Practice Address - Phone:813-265-0210
Practice Address - Fax:813-265-0218
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-05-2597103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst