Healthcare Provider Details

I. General information

NPI: 1164046884
Provider Name (Legal Business Name): MARY TERESA GAINEY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PARKWOOD DR
BRUNSWICK GA
31520-4719
US

IV. Provider business mailing address

2300 PARKWOOD DR
BRUNSWICK GA
31520-4719
US

V. Phone/Fax

Practice location:
  • Phone: 912-399-4247
  • Fax: 912-574-5919
Mailing address:
  • Phone: 912-399-4247
  • Fax: 912-574-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-119849
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-51994
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: