Provider Demographics
NPI:1336777564
Name:SCHRECK, KAELYN
Entity type:Individual
Prefix:
First Name:KAELYN
Middle Name:
Last Name:SCHRECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S MYRTLE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3406
Mailing Address - Country:US
Mailing Address - Phone:626-775-8888
Mailing Address - Fax:
Practice Address - Street 1:9229 UTICA AVE STE 130
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5461
Practice Address - Country:US
Practice Address - Phone:909-689-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-69212103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician