Individual
CAITLIN OWEN RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
124 CAPULET DR, ST AUGUSTINE, FL 32092-4537
(904) 429-3859
Mailing address
175 MIDDLE ST UNIT 1201, LAKE MARY, FL 32746-3625
(866) 610-0580
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
12152029
FL
106S00000X
Behavior Technician
RBT-17-38028
FL
Other
Enumeration date
01/15/2018
Last updated
08/09/2021
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