Provider Demographics
NPI:1417564493
Name:TITKEMEYER, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:TITKEMEYER
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 1:121 N HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-5764
Mailing Address - Country:US
Mailing Address - Phone:321-356-8429
Mailing Address - Fax:
Practice Address - Street 1:121 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-5764
Practice Address - Country:US
Practice Address - Phone:321-356-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician