Provider Demographics
NPI:1760107890
Name:ALSTON, DARYL-LESHA KOREA (RBT)
Entity Type:Individual
Prefix:MISS
First Name:DARYL-LESHA
Middle Name:KOREA
Last Name:ALSTON
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 1:3875 DARIEN HWY APT 9C
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-2495
Mailing Address - Country:US
Mailing Address - Phone:912-297-7165
Mailing Address - Fax:
Practice Address - Street 1:408 BEDELL AVE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-3585
Practice Address - Country:US
Practice Address - Phone:912-409-7889
Practice Address - Fax:404-953-7889
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-238301106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty