Healthcare Provider Details

I. General information

NPI: 1356282982
Provider Name (Legal Business Name): KAITLEN AUTREY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S FERDON BLVD STE B3
CRESTVIEW FL
32536-5287
US

IV. Provider business mailing address

PO BOX 259
SHALIMAR FL
32579-0259
US

V. Phone/Fax

Practice location:
  • Phone: 850-362-6824
  • Fax: 850-362-6826
Mailing address:
  • Phone: 850-362-6824
  • Fax: 850-362-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: