Provider Demographics
NPI:1184075483
Name:MOSS, KAYLIN MELISSA
Entity type:Individual
Prefix:
First Name:KAYLIN
Middle Name:MELISSA
Last Name:MOSS
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 1:11907 STURBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5715
Mailing Address - Country:US
Mailing Address - Phone:561-301-8330
Mailing Address - Fax:
Practice Address - Street 1:11907 STURBRIDGE LN
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-5715
Practice Address - Country:US
Practice Address - Phone:561-301-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
FL1-19-40133103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017975700Medicaid
FL110018700Medicaid