Healthcare Provider Details

I. General information

NPI: 1649102112
Provider Name (Legal Business Name): KRISALYN MIKAYLA FIRESTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

114 LITTLE FARM LN
KATHLEEN GA
31047-2614
US

V. Phone/Fax

Practice location:
  • Phone: 772-349-6317
  • Fax:
Mailing address:
  • Phone: 478-230-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: