Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | RBT-19-81230 | GA |
NPI | 1003375619 |
---|---|
Provider Name | Angela Kallio-Crotteau |
First Address | Ponte Vedra Beach, FL 32004-7833 |
Second Address | Richmond Hill, GA 31324-8601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2019 |
Last Update Date | 15/03/2019 |