Provider Demographics
NPI:1275282451
Name:DANIELS, KIZZY
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:
Last Name:DANIELS
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 1:240 NEW FRANKLIN RD # 1013
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2344
Mailing Address - Country:US
Mailing Address - Phone:615-479-5330
Mailing Address - Fax:
Practice Address - Street 1:240 NEW FRANKLIN RD # 1013
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2344
Practice Address - Country:US
Practice Address - Phone:615-479-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
GABACB485358103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst