Healthcare Provider Details

I. General information

NPI: 1235961830
Provider Name (Legal Business Name): FOOTHILLS BEHAVIOR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PROFESSIONAL PARK DR
CLARKESVILLE GA
30523-5524
US

IV. Provider business mailing address

125 PROFESSIONAL PARK DR
CLARKESVILLE GA
30523-5524
US

V. Phone/Fax

Practice location:
  • Phone: 734-626-0769
  • Fax:
Mailing address:
  • Phone: 734-626-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
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. LISA M NALLEY
Title or Position: OWNER/BCBA
Credential: M.ED., BCBA
Phone: 734-626-0769