Basic Information
| Provider Information | |||||||||
| NPI: | 1730578444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KELSEY | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4910 WHITE SANDERLING CT | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336190823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742063561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6507 GUNN HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133742070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2015 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-9733 | OH | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 004331400 | 05 | FL | MEDICAID |