=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003463670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELIZABETH MINTON MS, BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2019
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1835 DAVIE AVE STE 413
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677-3578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-572-3810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 BRAWLEY SCHOOL RD #104, MOORESVILLE, NC 28117
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-6876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-703-8588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-24-73157
-----------------------------------------------------
License Number State |
-----------------------------------------------------