=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578332805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. TAYLOR BURCH GIBSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2023
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 TORI DR STE 2
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-5209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-800-0891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 HERSCHEL DR APT B
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-2375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-292-3854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------