Provider Demographics
NPI:1619584901
Name:MEDLEY, KIZZY GIBBS (RBT)
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:GIBBS
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:KIZZY
Other - Middle Name:EARLENA
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:126 PAVILION PKWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4056
Practice Address - Country:US
Practice Address - Phone:770-954-8988
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-131469106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician