Provider Demographics
NPI:1699328526
Name:MALLARD, KAYLON V (RBT)
Entity type:Individual
Prefix:
First Name:KAYLON
Middle Name:V
Last Name:MALLARD
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 1:4385 PRINCE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-5649
Mailing Address - Country:US
Mailing Address - Phone:321-460-3581
Mailing Address - Fax:
Practice Address - Street 1:4385 PRINCE HALL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-5649
Practice Address - Country:US
Practice Address - Phone:321-460-3581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018717800Medicaid