Organization
SOUTHSIDE ABA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHRISTINE ELAINE MARRERO BCBA (CLINICAL DIRECTOR)
(770) 707-6367
Entity
Organization
Contact information
Practice address
1135 SENOIA RD, TYRONE, GA 30290-1625
(770) 626-3044
(470) 200-2269
Mailing address
1135 SENOIA RD, TYRONE, GA 30290-1625
(770) 626-3044
(470) 200-2269
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003218736A
—
GA
Enumeration date
01/23/2020
Last updated
01/23/2020
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