Provider Demographics
NPI:1679031157
Name:CERNOSEK, KALEIGH RAE
Entity type:Individual
Prefix:
First Name:KALEIGH
Middle Name:RAE
Last Name:CERNOSEK
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 1:3771 STEFANI RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7795
Mailing Address - Country:US
Mailing Address - Phone:850-607-6910
Mailing Address - Fax:850-607-6932
Practice Address - Street 1:6465 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1301
Practice Address - Country:US
Practice Address - Phone:850-910-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-76699103K00000X
FL19-79066106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst