Provider Demographics
NPI:1548831902
Name:EBERHARDT, KANISHA NICOLE (QASP-S)
Entity type:Individual
Prefix:MS
First Name:KANISHA
Middle Name:NICOLE
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:QASP-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 WHEELER RD STE 320
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6552
Mailing Address - Country:US
Mailing Address - Phone:706-842-3279
Mailing Address - Fax:
Practice Address - Street 1:3633 WHEELER RD STE 320
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6552
Practice Address - Country:US
Practice Address - Phone:706-842-3279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-119073247200000X
11343106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other