Healthcare Provider Details

I. General information

NPI: 1558938704
Provider Name (Legal Business Name): SHAKIRRAH GUMBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 PEACHTREE DUNWOODY RD BLDG A1
ATLANTA GA
30328-6769
US

IV. Provider business mailing address

6849 PEACHTREE DUNWOODY RD BLDG A1
ATLANTA GA
30328-6769
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-2206
  • Fax:
Mailing address:
  • Phone: 678-691-2206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-165980
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: