Provider Demographics
NPI:1851974422
Name:MIDDLEBROOKS, KALILAH
Entity Type:Individual
Prefix:
First Name:KALILAH
Middle Name:
Last Name:MIDDLEBROOKS
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 1:1105 TOWN BLVD NE UNIT 1301
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3168
Mailing Address - Country:US
Mailing Address - Phone:770-584-0649
Mailing Address - Fax:
Practice Address - Street 1:1105 TOWN BLVD NE UNIT 1301
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3168
Practice Address - Country:US
Practice Address - Phone:770-584-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician