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General NPI Number Information
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NPI Number | 1689802779
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Entity Type | Organization
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Legal Business Name | KICKLIGHTER RESOURCE CENTER
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Dates
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Enumeration Date | 06/26/2009
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Last Update Date | 05/25/2023
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Provider Practice Location Address
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Address Line | 7219 SEAWRIGHT DR
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City | SAVANNAH
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State | GA
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Zip | 31406-2703
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Country | US
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Telephone | 912-355-7633
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Fax | 912-355-4206
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Provider Business Mailing Address
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Address Line | PO BOX 13625
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City | SAVANNAH
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State | GA
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Zip | 31416-0625
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Country | US
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Telephone | 912-355-7633
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Fax | 912-355-4206
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Authorized Official
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Title or Position | CEO/EXECUTIVE DIRECTOR
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Name | STACEY DAVIS
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Credential |
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Telephone | 912-355-7633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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