Provider Demographics
NPI:1215337449
Name:KINARD, PHILIP (MED, BCBA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:KINARD
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 PERIMETER PARK RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1975
Mailing Address - Country:US
Mailing Address - Phone:904-753-0701
Mailing Address - Fax:
Practice Address - Street 1:1838 PERIMETER PARK RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1975
Practice Address - Country:US
Practice Address - Phone:904-753-0701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-11-8789103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst