Provider Demographics
NPI:1174062335
Name:TAVARES, KELSEY ANN (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:ANN
Last Name:TAVARES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ANN
Other - Last Name:MCCABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:128 HAWTHORNE COURT
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866
Mailing Address - Country:US
Mailing Address - Phone:201-259-2587
Mailing Address - Fax:
Practice Address - Street 1:9 HEARTHSTONE DR
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2303
Practice Address - Country:US
Practice Address - Phone:201-259-2587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-16-24753103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst