Healthcare Provider Details

I. General information

NPI: 1588587760
Provider Name (Legal Business Name): KAVONNA FAYE KIRKSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83589 SHADOWROCK DR
COACHELLA CA
92236-5377
US

IV. Provider business mailing address

473 E CARNEGIE DR STE 200
SAN BERNARDINO CA
92408-4201
US

V. Phone/Fax

Practice location:
  • Phone: 214-970-3023
  • Fax:
Mailing address:
  • Phone: 214-970-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: