Healthcare Provider Details

I. General information

NPI: 1215692942
Provider Name (Legal Business Name): ALETHEA FAGGETT RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3338 TRICKUM RD
WOODSTOCK GA
30188-4242
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 470-472-0039
  • Fax: 317-520-8200
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-191853
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: