Provider Demographics
NPI:1699380576
Name:GIBBS, BIANCA ELLIE
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:ELLIE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:ELLIE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 E GENERAL STEWART WAY STE 202B
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2630
Mailing Address - Country:US
Mailing Address - Phone:912-294-4055
Mailing Address - Fax:866-467-4321
Practice Address - Street 1:740 E GENERAL STEWART WAY STE 202B
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2630
Practice Address - Country:US
Practice Address - Phone:912-294-4055
Practice Address - Fax:866-467-4321
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-134026106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT-20-134026OtherBACB