Healthcare Provider Details

I. General information

NPI: 1689802779
Provider Name (Legal Business Name): KICKLIGHTER RESOURCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 SEAWRIGHT DR
SAVANNAH GA
31406-2703
US

IV. Provider business mailing address

PO BOX 13625
SAVANNAH GA
31416-0625
US

V. Phone/Fax

Practice location:
  • Phone: 912-355-7633
  • Fax: 912-355-4206
Mailing address:
  • Phone: 912-355-7633
  • Fax: 912-355-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACEY DAVIS
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential:
Phone: 912-355-7633