Provider Demographics
NPI:1689276214
Name:GILLARD, TANEKA (RBT)
Entity Type:Individual
Prefix:
First Name:TANEKA
Middle Name:
Last Name:GILLARD
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-0003
Mailing Address - Country:US
Mailing Address - Phone:813-763-5469
Mailing Address - Fax:813-438-8909
Practice Address - Street 1:92 TEMPEST LN
Practice Address - Street 2:
Practice Address - City:ALLENHURST
Practice Address - State:GA
Practice Address - Zip Code:31301-2506
Practice Address - Country:US
Practice Address - Phone:910-554-5954
Practice Address - Fax:813-438-8903
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-14-141069106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician