Provider Demographics
NPI:1932733417
Name:KELLY, DONNA (BCBA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:KELLY
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 1:41690 ENTERPRISE CIR N STE 114
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5617
Mailing Address - Country:US
Mailing Address - Phone:951-667-9631
Mailing Address - Fax:
Practice Address - Street 1:41690 ENTERPRISE CIR N STE 114
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5617
Practice Address - Country:US
Practice Address - Phone:951-667-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician