MEDICARE: KAYLAVICTORIA OBAMWONYI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst	0-17-8157	FL
2	222Q00000X	Developmental Therapist
3	235Z00000X	Speech-Language Pathologist	SZ11691	FL
4	103K00000X	Behavior Analyst	0-21-54658	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093193021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLAVICTORIA OBAMWONYI

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:	317-520-8200

Provider Business Practice Location Address
First Line	:	4150 FORD ST STE 4
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-9498
Country	:	US
Telephone Number	:	239-291-5088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	01/17/2024

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Directions to “ KAYLAVICTORIA OBAMWONYI ” Practice Location

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