Basic Information
Provider Information | |||||||||
NPI: | 1205456902 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERN | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LBS, BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 785 5TH AVE STE 3 | ||||||||
Address2: |   | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172014232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172639555 | ||||||||
FaxNumber: | 7177096529 | ||||||||
Practice Location | |||||||||
Address1: | 2501 OREGON PIKE | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176014890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177351954 | ||||||||
FaxNumber: | 7172702472 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2020 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BH002799 | PA | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 14675449 | 01 |   | CAQH ID | OTHER | BH002799 | 01 | PA | STATE LICENSE - BEHAVIOR SPECIALIST | OTHER |