Provider Demographics
NPI:1942888797
Name:MILLENDER, KATELYN ROSE (RBT)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:MILLENDER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 STATE HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-7404
Mailing Address - Country:US
Mailing Address - Phone:850-585-9189
Mailing Address - Fax:850-951-0898
Practice Address - Street 1:128 JOHN KING RD STE 18
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5731
Practice Address - Country:US
Practice Address - Phone:850-333-1279
Practice Address - Fax:850-634-6079
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-162385106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician