Healthcare Provider Details

I. General information

NPI: 1760992499
Provider Name (Legal Business Name): KYLE MILLER BLOUNT BEHAVIOR ASSISTAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5695 CENTURY 21 BLVD
ORLANDO FL
32807-2215
US

IV. Provider business mailing address

500 E COLONIAL DR
ORLANDO FL
32803-4504
US

V. Phone/Fax

Practice location:
  • Phone: 727-421-7793
  • Fax:
Mailing address:
  • Phone: 407-218-4340
  • Fax: 407-218-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-72737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: