Healthcare Provider Details

I. General information

NPI: 1043867138
Provider Name (Legal Business Name): KALI BRUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3766 US HIGHWAY 17 STE 301
RICHMOND HILL GA
31324-8876
US

IV. Provider business mailing address

10175 FORTUNE PKWY UNIT 903
JACKSONVILLE FL
32256-6755
US

V. Phone/Fax

Practice location:
  • Phone: 912-445-2344
  • Fax: 904-538-0714
Mailing address:
  • Phone: 904-538-0713
  • Fax: 904-538-0714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-62589
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-96760
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: