Healthcare Provider Details

I. General information

NPI: 1619492253
Provider Name (Legal Business Name): BECKHOM BEHAVIORAL CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 W 3RD AVE
ALBANY GA
31707-3647
US

IV. Provider business mailing address

PO BOX 51293
ALBANY GA
31703-1293
US

V. Phone/Fax

Practice location:
  • Phone: 229-439-9951
  • Fax: 229-439-9553
Mailing address:
  • Phone: 229-439-9951
  • Fax: 229-439-9553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-03-1465
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATRINA MICHELLE WILBURN-BECKHOM
Title or Position: PROGRAM DIRECTOR
Credential: BCBA
Phone: 229-439-9951