Healthcare Provider Details

I. General information

NPI: 1548831902
Provider Name (Legal Business Name): KANISHA NICOLE EBERHARDT QASP-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD STE 320
AUGUSTA GA
30909-6552
US

IV. Provider business mailing address

3633 WHEELER RD STE 320
AUGUSTA GA
30909-6552
US

V. Phone/Fax

Practice location:
  • Phone: 706-842-3279
  • Fax:
Mailing address:
  • Phone: 706-842-3279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberRBT-20-119073
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number11343
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: