MEDICARE: MIRANDA TAYLOR GIBBS BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1306631619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA TAYLOR GIBBS BCBA

Provider Business Mailing Address
First Line	:	1894 LIBERTY LN
Second Line	:
City	:	GOSHEN
State	:	KY
Zip	:	40026-8746
Country	:	US
Telephone Number	:	636-675-5348
Fax Number	:

Provider Business Practice Location Address
First Line	:	8735 OLD BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-4490
Country	:	US
Telephone Number	:	502-208-6650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	04/09/2025

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