Healthcare Provider Details

I. General information

NPI: 1952908774
Provider Name (Legal Business Name): KAITLYN MIRANDA CROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 PEACHTREE ST NE STE 570
ATLANTA GA
30308-1244
US

IV. Provider business mailing address

5641 ROSWELL RD UNIT 201
ATLANTA GA
30342-1208
US

V. Phone/Fax

Practice location:
  • Phone: 877-733-7033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: