Provider Demographics
NPI:1659514180
Name:MATTICE, KRISTY LEE (BCABA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LEE
Last Name:MATTICE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SARNO RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4938
Mailing Address - Country:US
Mailing Address - Phone:321-752-3108
Mailing Address - Fax:321-752-3114
Practice Address - Street 1:1600 SARNO RD
Practice Address - Street 2:SUITE 214
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-752-3108
Practice Address - Fax:321-752-3114
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-04-1436103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst