Provider Demographics
NPI:1629503784
Name:BOBERG, CAITLYN
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:BOBERG
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 1:6082 50TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-3523
Mailing Address - Country:US
Mailing Address - Phone:727-541-5304
Mailing Address - Fax:727-546-8527
Practice Address - Street 1:8254 118TH AVENUE NORTH
Practice Address - Street 2:STE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5027
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:727-546-8527
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-17-41561106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician