Provider Demographics
NPI:1669960860
Name:WILSON, KEVA (BCBA)
Entity type:Individual
Prefix:
First Name:KEVA
Middle Name:
Last Name:WILSON
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 1:1040 CAMBRIDGE SQ STE A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1800
Mailing Address - Country:US
Mailing Address - Phone:678-883-8208
Mailing Address - Fax:678-530-1163
Practice Address - Street 1:1040 CAMBRIDGE SQ STE A
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1800
Practice Address - Country:US
Practice Address - Phone:678-883-8208
Practice Address - Fax:678-530-1163
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-26077103K00000X
1-17-26077103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-17-26077OtherBCBA CERTIFICATION NUMBER