MEDICARE: KYLEE ANN LANDISE

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1689507535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLEE ANN LANDISE

Provider Business Mailing Address
First Line	:	296 MERCHANTS SQ
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-5029
Country	:	US
Telephone Number	:	470-391-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	296 MERCHANTS SQ
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-5029
Country	:	US
Telephone Number	:	470-391-2300
Fax Number	:

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

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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Directions to “ KYLEE ANN LANDISE ” Practice Location

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