Provider Demographics
NPI:1427783646
Name:SOSSAMON, KAYLI
Entity type:Individual
Prefix:
First Name:KAYLI
Middle Name:
Last Name:SOSSAMON
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 1:5021 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-9450
Mailing Address - Country:US
Mailing Address - Phone:479-410-7495
Mailing Address - Fax:
Practice Address - Street 1:4300 ROGERS AVE STE 26
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3152
Practice Address - Country:US
Practice Address - Phone:479-867-4988
Practice Address - Fax:501-325-1255
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-12-11455106S00000X
AR1-24-73536103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1905152952OtherHOPE 4 AUTISM