Provider Demographics
NPI:1700657012
Name:ANDERSON, TAISHONA KATAVIA (RBT)
Entity type:Individual
Prefix:
First Name:TAISHONA
Middle Name:KATAVIA
Last Name:ANDERSON
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 1:1192 OLD GRUBBY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6140
Mailing Address - Country:US
Mailing Address - Phone:434-446-2921
Mailing Address - Fax:
Practice Address - Street 1:1100 CONFROY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-7162
Practice Address - Country:US
Practice Address - Phone:434-835-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-23-313698106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician