MEDICARE: LATISHA MARIE GARY 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	1-21-49048	NC

General Provider Information

NPI Number	:	1982118311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISHA MARIE GARY BCBA

Provider Business Mailing Address
First Line	:	8530 CLIFF CAMERON DR STE 140
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8530 CLIFF CAMERON DR STE 140
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5906
Country	:	US
Telephone Number	:	980-202-7441
Fax Number	:

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

Provider Enumeration Date	:	11/21/2017
Last Update Date	:	11/12/2023

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