Healthcare Provider Details

I. General information

NPI: 1942136593
Provider Name (Legal Business Name): ABA MOGUL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4695 N CHURCH LN SE APT 12301
ATLANTA GA
30339-0514
US

IV. Provider business mailing address

4695 N CHURCH LN SE APT 12301
ATLANTA GA
30339-0514
US

V. Phone/Fax

Practice location:
  • Phone: 470-817-2219
  • Fax:
Mailing address:
  • Phone: 470-817-2219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MANYA JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, BCBA
Phone: 470-817-2219