MEDICARE: JAMES AUSTIN MCKELLAR

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	106S00000X	Behavior Technician	RBT-22-233371	GA

General Provider Information

NPI Number	:	1821796814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES AUSTIN MCKELLAR

Provider Business Mailing Address
First Line	:	5931 SEQUOIA LN
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-5577
Country	:	US
Telephone Number	:	607-205-4841
Fax Number	:

Provider Business Practice Location Address
First Line	:	667 FAIRBURN RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-1423
Country	:	US
Telephone Number	:	404-586-9595
Fax Number	:

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

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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