=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033894704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUCKEYE BEHAVIORAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5030 EDINBURGH TER NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-558-9809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5030 EDINBURGH TER NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-558-9809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER /AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | REBECCA SARTAIN
-----------------------------------------------------
Credential | MS BCBA
-----------------------------------------------------
Telephone | 404-558-9809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------