=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114528916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLEE SHAY STIPE M.A., BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2020
-----------------------------------------------------
Last Update Date | 07/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6075 NAILS FERRY RD
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-2680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-1064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6075 NAILS FERRY RD
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-2680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-1064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-24-74067
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------