Provider Demographics
NPI:1902514706
Name:SUBANTO, KENIA ARBOLAEZ (RBT)
Entity Type:Individual
Prefix:MS
First Name:KENIA
Middle Name:ARBOLAEZ
Last Name:SUBANTO
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 1:959 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1984
Mailing Address - Country:US
Mailing Address - Phone:706-507-9127
Mailing Address - Fax:706-780-1705
Practice Address - Street 1:3870 SAN JOSE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILL
Practice Address - State:FL
Practice Address - Zip Code:32217
Practice Address - Country:US
Practice Address - Phone:706-507-9216
Practice Address - Fax:706-780-1705
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-227895106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty