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General NPI Number Information
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NPI Number | 1801449558
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Entity Type | Individual
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Provider Name | CANDICE KENNERLY
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Gender | Female
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Dates
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Enumeration Date | 07/22/2019
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 520 PALM COAST PKWY SW STE 103
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City | PALM COAST
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State | FL
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Zip | 32137-4743
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Country | US
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Telephone | 386-225-4940
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Fax |
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Provider Business Mailing Address
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Address Line | 1 BLAINE DR
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City | PALM COAST
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State | FL
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Zip | 32137-7324
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number | 0-19-9711
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License Number State | FL
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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 | 1-23-69822
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License Number State | FL
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