Provider Demographics
NPI:1336804194
Name:THAXTON, GENESIS LENORA IMANI (BT)
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:LENORA IMANI
Last Name:THAXTON
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14246 CRYSTAL KEY PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5201
Mailing Address - Country:US
Mailing Address - Phone:757-401-0979
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE ST STE 60
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4650
Practice Address - Country:US
Practice Address - Phone:407-559-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician