Healthcare Provider Details

I. General information

NPI: 1609715713
Provider Name (Legal Business Name): N/A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 MASTERS DR
MONROE GA
30655-8483
US

IV. Provider business mailing address

957 MASTERS DR
MONROE GA
30655-8483
US

V. Phone/Fax

Practice location:
  • Phone: 770-883-9181
  • Fax:
Mailing address:
  • Phone: 770-883-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MS. TERRIBIA SADE BYNUM
Title or Position: REGISTERED BEHAVIOR TECHNICIAN
Credential: RBT
Phone: 770-883-9181