Healthcare Provider Details

I. General information

NPI: 1053559971
Provider Name (Legal Business Name): INNOVATIVE BEHAVIOR OPTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 LYNDHURST WAY
ROSWELL GA
30075-2584
US

IV. Provider business mailing address

1365 LYNDHURST WAY
ROSWELL GA
30075-2584
US

V. Phone/Fax

Practice location:
  • Phone: 770-992-8534
  • Fax:
Mailing address:
  • Phone: 770-992-8534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1052566
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-05-2566
License Number StateGA

VIII. Authorized Official

Name: MRS. ROBIN DAWN STONE
Title or Position: OWNER AND BEHAVIOR ANALYST
Credential: M.S., BCBA
Phone: 770-992-8534