Healthcare Provider Details

I. General information

NPI: 1336804194
Provider Name (Legal Business Name): GENESIS LENORA IMANI THAXTON BT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 W VINE ST STE 60
KISSIMMEE FL
34741-4650
US

IV. Provider business mailing address

14246 CRYSTAL KEY PL
ORLANDO FL
32824-5201
US

V. Phone/Fax

Practice location:
  • Phone: 407-559-4854
  • Fax:
Mailing address:
  • Phone: 757-401-0979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: