MEDICARE: ANYSA GOURDINE

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	106S00000X	Behavior Technician	RBT-23-485565	VA

General Provider Information

NPI Number	:	1588528822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANYSA GOURDINE

Provider Business Mailing Address
First Line	:	2206 EXECUTIVE DR STE A
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-2583
Country	:	US
Telephone Number	:	757-664-9778
Fax Number	:	757-903-0114

Provider Business Practice Location Address
First Line	:	2206 EXECUTIVE DR STE A
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-2583
Country	:	US
Telephone Number	:	757-664-9778
Fax Number	:	757-903-0114

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

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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Directions to “ ANYSA GOURDINE ” Practice Location

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