=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780234641
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEONNA MONIQUE KIRKWOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2019
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8282 28TH CT NE STE A
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98516-7162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-915-6868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 ORCHARD ST W APT F112
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98467-3833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-592-1600
-----------------------------------------------------
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 |
-----------------------------------------------------