Provider Demographics
NPI:1093287278
Name:LITTLE, KASSIDY RENEE
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:RENEE
Last Name:LITTLE
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 1:1750 COMMERCE CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6333
Mailing Address - Country:US
Mailing Address - Phone:937-874-8444
Mailing Address - Fax:
Practice Address - Street 1:1750 COMMERCE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6333
Practice Address - Country:US
Practice Address - Phone:937-874-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-18-72633106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician