Individual
NAA Y ODEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
BCBA, NCSP
Contact information
Practice address
4813 RIDGE RD STE 111-639, DOUGLASVILLE, GA 30134
(330) 622-3766
(404) 225-1840
Mailing address
4813 RIDGE RD STE 111-639, DOUGLASVILLE, GA 30134-6117
(330) 622-3766
(404) 225-1840
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
1-19-35830
GA
103TS0200X
School Psychologist
OH3043645
OH
Other
Enumeration date
02/10/2014
Last updated
07/01/2019
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