Healthcare Provider Details

I. General information

NPI: 1134936768
Provider Name (Legal Business Name): IMANI WINCHESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 TERRY LN
GREENSBORO NC
27405-3043
US

IV. Provider business mailing address

3621 MARION LN
LAS CRUCES NM
88012-7579
US

V. Phone/Fax

Practice location:
  • Phone: 336-490-4087
  • Fax:
Mailing address:
  • Phone: 505-929-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-81220
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: