Healthcare Provider Details

I. General information

NPI: 1215855655
Provider Name (Legal Business Name): MARISELA ALICIA AGUILAR LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 BULLY BLVD.
MISSISSIPPI STATE MS
39762
US

IV. Provider business mailing address

PO BOX 6338
MISSISSIPPI STATE MS
39762-6338
US

V. Phone/Fax

Practice location:
  • Phone: 662-325-5895
  • Fax:
Mailing address:
  • Phone: 662-325-5895
  • Fax: 662-325-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number261003
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: