Provider Demographics
NPI:1356939839
Name:KELLY, KARYN (BCBA)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:
Last Name:KELLY
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 1:8625 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7074
Mailing Address - Country:US
Mailing Address - Phone:732-858-1824
Mailing Address - Fax:866-477-3119
Practice Address - Street 1:8625 ASPEN CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7074
Practice Address - Country:US
Practice Address - Phone:732-858-1824
Practice Address - Fax:866-477-3119
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-20-46392103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1-20-46392OtherBACB CERTIFICATION