Provider Demographics
NPI:1942080544
Name:SIMONIDES, KAITLIN SANDRA
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:SANDRA
Last Name:SIMONIDES
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 1:107 BRYSON CIR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-4394
Mailing Address - Country:US
Mailing Address - Phone:914-299-5806
Mailing Address - Fax:
Practice Address - Street 1:107 BRYSON CIR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-4394
Practice Address - Country:US
Practice Address - Phone:914-299-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-286206106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician