Healthcare Provider Details

I. General information

NPI: 1275204968
Provider Name (Legal Business Name): THE BAULCH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 WILL ROBBINS HWY
NETTLETON MS
38858-6062
US

IV. Provider business mailing address

425 HIGHWAY 6
NETTLETON MS
38858-9561
US

V. Phone/Fax

Practice location:
  • Phone: 662-213-5815
  • Fax:
Mailing address:
  • Phone: 662-213-5815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DEANA S. BAULCH
Title or Position: OWNER
Credential: EDD
Phone: 662-213-5815