Provider Demographics
NPI:1881398659
Name:SCANLON, KAITLIN MARIE ISLEY
Entity type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:MARIE ISLEY
Last Name:SCANLON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KAITLIN
Other - Middle Name:MARIE
Other - Last Name:ISLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 FAIRWAY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1834
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:1320 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3266
Practice Address - Country:US
Practice Address - Phone:360-224-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
SC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician