Provider Demographics
NPI:1003196098
Name:CARPENTER, KAYLON MIMS
Entity Type:Individual
Prefix:
First Name:KAYLON
Middle Name:MIMS
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7026 SOUTHGATE DR SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-9289
Mailing Address - Country:US
Mailing Address - Phone:205-862-3365
Mailing Address - Fax:
Practice Address - Street 1:7026 SOUTHGATE DR SE
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-9289
Practice Address - Country:US
Practice Address - Phone:205-862-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AL2017-123103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst