Provider Demographics
NPI:1194233932
Name:CHANDLER, KENYATTA (BA)
Entity type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 EDGEWATER DR # 2297
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:407-267-3566
Mailing Address - Fax:
Practice Address - Street 1:1317 EDGEWATER DR # 2297
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6350
Practice Address - Country:US
Practice Address - Phone:407-734-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105324200Medicaid