Provider Demographics
NPI:1558935197
Name:DEGNAN, KELLIE (RBT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DEGNAN
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 1:5276 HIGHWAY 17 BUSINESS
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5214
Mailing Address - Country:US
Mailing Address - Phone:413-519-6938
Mailing Address - Fax:
Practice Address - Street 1:5276 HIGHWAY 17 BUSINESS
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5214
Practice Address - Country:US
Practice Address - Phone:843-449-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19-102250106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician