Provider Demographics
NPI:1225706641
Name:BRANTLEY, KYLIE KANEHL
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:KANEHL
Last Name:BRANTLEY
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 1:103 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5447
Mailing Address - Country:US
Mailing Address - Phone:912-547-2982
Mailing Address - Fax:
Practice Address - Street 1:105 GRAND CENTRAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4146
Practice Address - Country:US
Practice Address - Phone:912-388-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician