MEDICARE: KAYLEIGH DANIELLE RANDALL

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	:	1992595946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLEIGH DANIELLE RANDALL

Provider Business Mailing Address
First Line	:	4981 NORTHFIELD DR
Second Line	:
City	:	MONROE
State	:	MI
Zip	:	48161-5434
Country	:	US
Telephone Number	:	734-430-7572
Fax Number	:	734-430-7572

Provider Business Practice Location Address
First Line	:	4981 NORTHFIELD DR
Second Line	:
City	:	MONROE
State	:	MI
Zip	:	48161-5434
Country	:	US
Telephone Number	:	734-430-7572
Fax Number	:	734-430-7572

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

Provider Enumeration Date	:	05/12/2025
Last Update Date	:	05/12/2025

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