Healthcare Provider Details

I. General information

NPI: 1750899589
Provider Name (Legal Business Name): CAITLIN OWEN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 CAPULET DR
ST AUGUSTINE FL
32092-4537
US

IV. Provider business mailing address

175 MIDDLE ST UNIT 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-3859
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12152029
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-38028
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: