Provider Demographics
NPI:1902411705
Name:GIST, SHAQUITA DAVIS (BA)
Entity Type:Individual
Prefix:
First Name:SHAQUITA
Middle Name:DAVIS
Last Name:GIST
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:SHAQUITA
Other - Middle Name:MARQUETT
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3800 CAMP CREEK PKWY SW STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-6247
Practice Address - Country:US
Practice Address - Phone:770-999-9271
Practice Address - Fax:317-520-8200
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-19-104734106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician