Healthcare Provider Details

I. General information

NPI: 1922816198
Provider Name (Legal Business Name): KAIE BRADY SIBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 N OHIO ST
DUNNELLON FL
34431-6724
US

IV. Provider business mailing address

7536 N GALENA AVE
CITRUS SPRINGS FL
34434-6606
US

V. Phone/Fax

Practice location:
  • Phone: 352-462-7021
  • Fax:
Mailing address:
  • Phone: 352-209-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24400881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: