MEDICARE: DOMINIC STEPHAN PADGETT BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-24-75018	GA

General Provider Information

NPI Number	:	1083446009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC STEPHAN PADGETT BCBA

Provider Business Mailing Address
First Line	:	5077 DALLAS HWY STE 301
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5077 DALLAS HWY STE 301
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4510
Country	:	US
Telephone Number	:	770-763-8592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	08/19/2024

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