Provider Demographics
NPI:1366118705
Name:KENYON, ETHAN M (RBT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:M
Last Name:KENYON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 E COLONIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4729
Mailing Address - Country:US
Mailing Address - Phone:407-218-4340
Mailing Address - Fax:407-218-4303
Practice Address - Street 1:500 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4510
Practice Address - Country:US
Practice Address - Phone:407-218-4340
Practice Address - Fax:407-218-4303
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-178116106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician