Provider Demographics
NPI:1194467092
Name:MUHAMMAD, KASHANTA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:KASHANTA
Middle Name:MICHELLE
Last Name:MUHAMMAD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KASHANTA
Other - Middle Name:MICHELLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2027 HIGHLAND PARC PL SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-2434
Mailing Address - Country:US
Mailing Address - Phone:470-535-3903
Mailing Address - Fax:
Practice Address - Street 1:3338 TRICKUM RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4242
Practice Address - Country:US
Practice Address - Phone:470-472-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-219489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician