Provider Demographics
NPI:1649677352
Name:KANTAWANG, LILLY (BCBA LBA)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:KANTAWANG
Suffix:
Gender:F
Credentials:BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3655
Mailing Address - Country:US
Mailing Address - Phone:347-369-2733
Mailing Address - Fax:
Practice Address - Street 1:1123 DICKENS ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2301
Practice Address - Country:US
Practice Address - Phone:347-369-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst