Provider Demographics
NPI:1275315335
Name:KISSANE, ALEXIS RENEE (RBT)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RENEE
Last Name:KISSANE
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 1:331 HILLSIDE PARK ST APT 6313
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-6168
Mailing Address - Country:US
Mailing Address - Phone:260-431-1525
Mailing Address - Fax:
Practice Address - Street 1:454 W PIPKIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2545
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-148899106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician