Provider Demographics
NPI:1356088892
Name:PRIDGEN, KAYLIN
Entity Type:Individual
Prefix:
First Name:KAYLIN
Middle Name:
Last Name:PRIDGEN
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 1:525 8TH ST
Mailing Address - Street 2:P.O. BOX 2567
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-9998
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:101 ROSSMORE PL
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5771
Practice Address - Country:US
Practice Address - Phone:706-842-5330
Practice Address - Fax:706-842-5340
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-215671106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician