Provider Demographics
NPI:1275315335
Name:KISSANE, ALEXIS RENEE (RBT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RENEE
Last Name:KISSANE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 LITCHFIELD LOOP
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3387
Mailing Address - Country:US
Mailing Address - Phone:260-431-1525
Mailing Address - Fax:
Practice Address - Street 1:2202 MANDARIN LOOP
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4387
Practice Address - Country:US
Practice Address - Phone:833-869-2423
Practice Address - Fax:863-869-6727
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-148899106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician