Provider Demographics
NPI:1255612289
Name:MANCIL, GREGORY RICHMOND (BCBA-D, LBA)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RICHMOND
Last Name:MANCIL
Suffix:
Gender:M
Credentials:BCBA-D, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 WAKEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1551
Mailing Address - Country:US
Mailing Address - Phone:502-298-6983
Mailing Address - Fax:
Practice Address - Street 1:730 FAIRVIEW AVENUE SUITE B-5
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-904-5071
Practice Address - Fax:270-904-5072
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-03
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0017103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst