Healthcare Provider Details

I. General information

NPI: 1730098021
Provider Name (Legal Business Name): THEMIAH SHAFAYE KENDRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 AVENUE A APT 7
BAINBRIDGE GA
39819-1125
US

IV. Provider business mailing address

1405 AVE A #7
BAINBRIDGE GA
39819
US

V. Phone/Fax

Practice location:
  • Phone: 229-205-3122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number060481582
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: