Healthcare Provider Details

I. General information

NPI: 1407533003
Provider Name (Legal Business Name): PERFORMANCE ABA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 STALLINGS ST NW # 2832
COVINGTON GA
30014-2351
US

IV. Provider business mailing address

2131 STALLINGS ST NW # 2832
COVINGTON GA
30014-2351
US

V. Phone/Fax

Practice location:
  • Phone: 770-895-2978
  • Fax:
Mailing address:
  • Phone: 770-895-2978
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: EBONY POWELL
Title or Position: OWNER
Credential:
Phone: 770-895-2978