Provider Demographics
NPI:1518628635
Name:BERHE, KALKIDAN GEZAEI
Entity Type:Individual
Prefix:
First Name:KALKIDAN
Middle Name:GEZAEI
Last Name:BERHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALKIDAN
Other - Middle Name:BERHE
Other - Last Name:GEZAEI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:9374 OLIVE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3253
Practice Address - Country:US
Practice Address - Phone:314-932-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician