Provider Demographics
NPI:1750841599
Name:ANTHONY, KIMBERLY LASHAUN (RBT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LASHAUN
Last Name:ANTHONY
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 1:1517 LILY POND RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-7771
Mailing Address - Country:US
Mailing Address - Phone:229-669-3311
Mailing Address - Fax:
Practice Address - Street 1:1517 LILY POND RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-7771
Practice Address - Country:US
Practice Address - Phone:229-669-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-74736106S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA071719050OtherDRIVERS LICENSE
GARBT-19-74736OtherRBT REGISTRATION NUMBER