Provider Demographics
NPI:1760992499
Name:BLOUNT, KYLE MILLER (BEHAVIOR ASSISTAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MILLER
Last Name:BLOUNT
Suffix:
Gender:M
Credentials:BEHAVIOR ASSISTAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4504
Mailing Address - Country:US
Mailing Address - Phone:407-218-4340
Mailing Address - Fax:407-218-4303
Practice Address - Street 1:5695 CENTURY 21 BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-2215
Practice Address - Country:US
Practice Address - Phone:727-421-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-72737106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019676400Medicaid