Provider Demographics
NPI:1043956535
Name:GONZALEZ, KEYLA M (BCBA)
Entity type:Individual
Prefix:
First Name:KEYLA
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1281
Mailing Address - Country:US
Mailing Address - Phone:774-241-0001
Mailing Address - Fax:508-462-5839
Practice Address - Street 1:54 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1281
Practice Address - Country:US
Practice Address - Phone:774-241-0013
Practice Address - Fax:508-462-5839
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA4051103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker