Healthcare Provider Details

I. General information

NPI: 1316544299
Provider Name (Legal Business Name): JHON KELLY MYRTIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3098 PIEDMONT RD NE STE 200
ATLANTA GA
30305-2600
US

IV. Provider business mailing address

542 AMHERST ST STE B
NASHUA NH
03063-1016
US

V. Phone/Fax

Practice location:
  • Phone: 855-724-9356
  • Fax:
Mailing address:
  • Phone: 844-923-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberM634431941440
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2836699
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: