Provider Demographics
NPI:1265059844
Name:DEFRANT, KETTLY E
Entity type:Individual
Prefix:
First Name:KETTLY
Middle Name:E
Last Name:DEFRANT
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 1:15648 SW 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4983
Mailing Address - Country:US
Mailing Address - Phone:786-556-1226
Mailing Address - Fax:
Practice Address - Street 1:3720 COCONUT CREEK PKWY STE D
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1634
Practice Address - Country:US
Practice Address - Phone:954-697-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117447106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician