Provider Demographics
NPI:1104299734
Name:VAN LAEKEN, KEVIN (BCBA, LEP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VAN LAEKEN
Suffix:
Gender:M
Credentials:BCBA, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 GREAT AMERICA PARKWAY
Mailing Address - Street 2:SUITE 320 #273
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054
Mailing Address - Country:US
Mailing Address - Phone:530-227-2883
Mailing Address - Fax:
Practice Address - Street 1:5201 GREAT AMERICA PARKWAY
Practice Address - Street 2:SUITE 320 #273
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054
Practice Address - Country:US
Practice Address - Phone:530-227-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3635103TM1800X, 103TB0200X
103K00000X
CALEP3635103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool