Provider Demographics
NPI:1467165704
Name:DAWSON, PERTANNICA A'NIYAH
Entity Type:Individual
Prefix:
First Name:PERTANNICA
Middle Name:A'NIYAH
Last Name:DAWSON
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 1:2001 SYLVAN RD SW APT 2D
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-5059
Mailing Address - Country:US
Mailing Address - Phone:229-288-5785
Mailing Address - Fax:
Practice Address - Street 1:1777 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-4159
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-251661106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician