Healthcare Provider Details

I. General information

NPI: 1811842727
Provider Name (Legal Business Name): HAILEE A KETTERER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CUMBERLAND PARK DR STE 100
SAINT AUGUSTINE FL
32095-8955
US

IV. Provider business mailing address

79 GLENNEYRE CIR
SAINT AUGUSTINE FL
32092-1211
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-9129
  • Fax:
Mailing address:
  • Phone: 801-718-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-513504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: