Provider Demographics
NPI:1497036594
Name:STEVENSON, KEELY (MED, BCBA)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:400 E ROYAL LN BLDG 3
Mailing Address - Street 2:SUITE 290
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3540
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:400 E ROYAL LN BLDG 3
Practice Address - Street 2:SUITE 290
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3540
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-08-4139103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst