Provider Demographics
NPI:1215619523
Name:GAYLE, TAKIRAH LASHAWN
Entity type:Individual
Prefix:
First Name:TAKIRAH
Middle Name:LASHAWN
Last Name:GAYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 VETERANS MEMORIAL HWY SW
Mailing Address - Street 2:SUITE 660
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:404-919-0409
Mailing Address - Fax:
Practice Address - Street 1:1025 VETERANS MEMORIAL HWY SW
Practice Address - Street 2:SUITE 660
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:404-919-0409
Practice Address - Fax:678-623-8220
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty