Healthcare Provider Details

I. General information

NPI: 1902089857
Provider Name (Legal Business Name): BEHAVIOR, ATTENTION, AND DEVELOPMENTAL DISABILITIES CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5779 GETWELL RD BLDG D3
SOUTHAVEN MS
38672-6351
US

IV. Provider business mailing address

4628 UNION RD
SARDIS MS
38666-3280
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-6507
  • Fax: 662-510-6508
Mailing address:
  • Phone: 662-609-4950
  • Fax: 844-445-7727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: EMILY THOMAS JOHNSON
Title or Position: OWNER
Credential: PH.D.
Phone: 662-609-4950