Provider Demographics
NPI:1679055396
Name:BUNDRICK, ANNA KAITLYN (BCBA)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:KAITLYN
Last Name:BUNDRICK
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 1:373 S WILLOW ST STE 266
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:877-315-8080
Mailing Address - Fax:877-345-4009
Practice Address - Street 1:1651 E. 70TH ST SUITE 2-A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA313103K00000X
LAL-313103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst