Basic Information
| Provider Information | |||||||||
| NPI: | 1497081491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIETO | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4325 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907034325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444222435 | ||||||||
| FaxNumber: | 5622197458 | ||||||||
| Practice Location | |||||||||
| Address1: | 19117 ALPHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907037215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444222435 | ||||||||
| FaxNumber: | 5622197458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-08-4472 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.