Healthcare Provider Details

I. General information

NPI: 1770411522
Provider Name (Legal Business Name): ISAIAH STANSBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PIPEMAKERS CIR STE 116
POOLER GA
31322-4168
US

IV. Provider business mailing address

110 PIPEMAKERS CIR STE 116
POOLER GA
31322-4168
US

V. Phone/Fax

Practice location:
  • Phone: 912-330-7171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-536773
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: