Healthcare Provider Details

I. General information

NPI: 1790239556
Provider Name (Legal Business Name): ELIZABETH WATHEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 02/01/2024
Certification Date: 01/30/2024
Deactivation Date: 01/04/2022
Reactivation Date: 02/28/2022

III. Provider practice location address

2329 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-4719
US

IV. Provider business mailing address

1720 PEACHTREE ST. NE UNIT 510
ATLANTA GA
30309
US

V. Phone/Fax

Practice location:
  • Phone: 770-637-2001
  • Fax:
Mailing address:
  • Phone: 989-397-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001502
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: