Provider Demographics
NPI:1619754215
Name:GIPSON, ELTA LYNNE
Entity Type:Individual
Prefix:
First Name:ELTA
Middle Name:LYNNE
Last Name:GIPSON
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 1:3871 STONE LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6938
Mailing Address - Country:US
Mailing Address - Phone:404-295-0200
Mailing Address - Fax:
Practice Address - Street 1:3871 STONE LAKE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-6938
Practice Address - Country:US
Practice Address - Phone:404-295-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician