=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205599420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAILEY INGO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2021
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 HIGHWAY 101
-----------------------------------------------------
City | LANDRUM
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29356-8980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-676-0028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 ELFORD CT
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29306-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-676-0028
-----------------------------------------------------
Fax | 864-476-0033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-21-181646
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-23-69362
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------