Provider Demographics
NPI:1376009860
Name:EDELMAN, KELLY A (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:EDELMAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JASINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:8700 PERSHING DRIVE UNIT #2110
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL ROY
Mailing Address - State:CA
Mailing Address - Zip Code:90293
Mailing Address - Country:US
Mailing Address - Phone:219-669-6916
Mailing Address - Fax:
Practice Address - Street 1:660 4TH ST STE 168
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-1618
Practice Address - Country:US
Practice Address - Phone:415-449-2813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA1-18-33404103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst