Provider Demographics
NPI:1376309823
Name:THURMOND, SEQUOYAH KIANI
Entity Type:Individual
Prefix:
First Name:SEQUOYAH
Middle Name:KIANI
Last Name:THURMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 DOWNSBURY RD
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-0438
Mailing Address - Country:US
Mailing Address - Phone:706-288-7587
Mailing Address - Fax:
Practice Address - Street 1:158 DOWNSBURY RD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-0438
Practice Address - Country:US
Practice Address - Phone:706-288-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT23264843106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician