Healthcare Provider Details

I. General information

NPI: 1275464869
Provider Name (Legal Business Name): KAMALIAH SCALLY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4029 KRUGER RD
THREE OAKS MI
49128-9523
US

IV. Provider business mailing address

51336 OUTER DR
SOUTH BEND IN
46628-9614
US

V. Phone/Fax

Practice location:
  • Phone: 605-519-1698
  • Fax:
Mailing address:
  • Phone: 605-519-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-539870
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: