Healthcare Provider Details

I. General information

NPI: 1144140617
Provider Name (Legal Business Name): KAZARIA MONEE FORTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 KIMBERLY WAY SW
MARIETTA GA
30064-3039
US

IV. Provider business mailing address

154 KIMBERLY WAY SW
MARIETTA GA
30064-3039
US

V. Phone/Fax

Practice location:
  • Phone: 404-784-4775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-473512
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: