Basic Information
| Provider Information | |||||||||
| NPI: | 1366961476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSGROVE | ||||||||
| FirstName: | KEITH | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16782 VON KARMAN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498332237 | ||||||||
| FaxNumber: | 9492534627 | ||||||||
| Practice Location | |||||||||
| Address1: | 94-849 LUMIAINA ST UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082947050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2017 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247000000X | CA | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.