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General NPI Number Information
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NPI Number | 1255612289
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Entity Type | Individual
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Provider Name | GREGORY RICHMOND MANCIL BCBA-D, LBA
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Gender | Male
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Dates
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Enumeration Date | 09/03/2011
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Last Update Date | 07/16/2012
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Provider Practice Location Address
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Address Line | 730 FAIRVIEW AVENUE SUITE B-5
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City | BOWLING GREEN
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State | KY
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Zip | 42101
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Country | US
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Telephone | 270-904-5071
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Fax | 270-904-5072
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Provider Business Mailing Address
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Address Line | 670 WAKEFIELD ST
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City | BOWLING GREEN
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State | KY
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Zip | 42103-1551
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Country | US
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Telephone | 502-298-6983
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | KY-0017
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License Number State | KY
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