Healthcare Provider Details

I. General information

NPI: 1942080544
Provider Name (Legal Business Name): KAITLIN SANDRA SIMONIDES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PAIGE CT
GOOSE CREEK SC
29445-7173
US

IV. Provider business mailing address

108 PAIGE CT
GOOSE CREEK SC
29445-7173
US

V. Phone/Fax

Practice location:
  • Phone: 914-299-5806
  • Fax:
Mailing address:
  • Phone: 914-299-5806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-26-17099
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: