Provider Demographics
NPI:1649744038
Name:SAN JUAN, KRISTAN KEVIN (BCABA)
Entity type:Individual
Prefix:
First Name:KRISTAN KEVIN
Middle Name:
Last Name:SAN JUAN
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:SAN JUAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:4774 SW 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4428
Mailing Address - Country:US
Mailing Address - Phone:786-239-6373
Mailing Address - Fax:
Practice Address - Street 1:777 BRICKELL AVE STE 500
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2803
Practice Address - Country:US
Practice Address - Phone:786-239-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9202106E00000X
FL1-21-56167103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst