Healthcare Provider Details

I. General information

NPI: 1144086307
Provider Name (Legal Business Name): KRISTINA BURDESHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 06/17/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 ENTERPRISE RD
ORANGE CITY FL
32763-8217
US

IV. Provider business mailing address

100 BENT TREE DR APT 171
DAYTONA BEACH FL
32114-1177
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax:
Mailing address:
  • Phone: 352-282-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-330039
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: