Provider Demographics
NPI:1154961274
Name:HERNANDEZ, KELLY RAY (MED, BCBA, LBA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RAY
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:YVONNE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA, LBA
Mailing Address - Street 1:1620 S HILL CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1184
Mailing Address - Country:US
Mailing Address - Phone:248-534-0678
Mailing Address - Fax:
Practice Address - Street 1:6510 TOWN CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4822
Practice Address - Country:US
Practice Address - Phone:248-277-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000984103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst