1154624658 NPI number — MS. KAITLIN MARY CORYAT FERNANDEZ M.A., BCBA, LBA

Table of content: MS. KAITLIN MARY CORYAT FERNANDEZ M.A., BCBA, LBA (NPI 1154624658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154624658 NPI number — MS. KAITLIN MARY CORYAT FERNANDEZ M.A., BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
KAITLIN
Provider Middle Name:
MARY CORYAT
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORYAT
Provider Other First Name:
KAITLIN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A., BCBA, LBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154624658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 DUNKIRK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21212-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-437-2815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 DUNKIRK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21212-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-437-2815
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-10-7532 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1-10-7532 . This is a "BEHAVIOR ANALYST CERTIFICATION BOARD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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