Provider Demographics
NPI:1114485265
Name:ELMORE, MIARA (RBT-19-80379)
Entity Type:Individual
Prefix:
First Name:MIARA
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:RBT-19-80379
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 13TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2248
Mailing Address - Country:US
Mailing Address - Phone:706-225-0101
Mailing Address - Fax:
Practice Address - Street 1:1133 13TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2248
Practice Address - Country:US
Practice Address - Phone:706-225-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-80379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT-19-80379OtherBACB