Provider Demographics
NPI:1316304181
Name:KENNEDY, KRYSTAL (MA BCBA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:JEANINE
Other - Last Name:QUALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA BCBA
Mailing Address - Street 1:1215 WAR EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38572-9009
Mailing Address - Country:US
Mailing Address - Phone:931-287-3710
Mailing Address - Fax:931-287-2778
Practice Address - Street 1:1215 WAR EAGLE DR
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38572-9009
Practice Address - Country:US
Practice Address - Phone:931-287-3710
Practice Address - Fax:931-287-2778
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11520978103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1-15-20978OtherBCBA CERTIFICATION #