Healthcare Provider Details

I. General information

NPI: 1346823168
Provider Name (Legal Business Name): LAUREN ASHLEY DERRICK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CEDAR HILL ST STE 200
MARLBOROUGH MA
01752-5900
US

IV. Provider business mailing address

104 E GORDON ST
VILLA RICA GA
30180-2018
US

V. Phone/Fax

Practice location:
  • Phone: 888-329-4535
  • Fax:
Mailing address:
  • Phone: 404-661-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-67425
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: