Basic Information
| Provider Information | |||||||||
| NPI: | 1659829000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMORE | ||||||||
| FirstName: | TANISHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 SANDY LN APT O7 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891155239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063256351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 731 MALL RING CIR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | RBT-16-23701 | NV | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | RBT-16-23701 | 01 | BCBA | OTHER |