Provider Demographics
NPI:1093577728
Name:EDENFIELD, KELSEY (BCBA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:EDENFIELD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-915-7729
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY BLDG. 600 STE 101
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-3355
Practice Address - Country:US
Practice Address - Phone:762-499-3476
Practice Address - Fax:762-499-5844
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-175019156F00000X
GA1-24-76267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist