Healthcare Provider Details

I. General information

NPI: 1366951865
Provider Name (Legal Business Name): HAILEY BLACKSTOCK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 WEBER INDUSTRIAL DR
CUMMING GA
30041-6468
US

IV. Provider business mailing address

352 MILL COVE DR
DAHLONEGA GA
30533-7617
US

V. Phone/Fax

Practice location:
  • Phone: 770-886-6204
  • Fax: 678-261-6421
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-26951
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: