Healthcare Provider Details

I. General information

NPI: 1750841599
Provider Name (Legal Business Name): KIMBERLY LASHAUN ANTHONY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 LILY POND RD
ALBANY GA
31701-7771
US

IV. Provider business mailing address

1517 LILY POND RD
ALBANY GA
31701-7771
US

V. Phone/Fax

Practice location:
  • Phone: 229-669-3311
  • Fax:
Mailing address:
  • Phone: 229-669-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-74736
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: