Provider Demographics
NPI:1215279963
Name:CEGLARZ, KELLY (MA, BCBA, LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CEGLARZ
Suffix:
Gender:F
Credentials:MA, BCBA, LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:FLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0042
Mailing Address - Country:US
Mailing Address - Phone:158-704-1334
Mailing Address - Fax:
Practice Address - Street 1:1252 NW ITHACA AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2221
Practice Address - Country:US
Practice Address - Phone:415-870-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8061103K00000X
CAIMF66109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst