=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518608868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P E A S BEHAVIOR GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2022
-----------------------------------------------------
Last Update Date | 09/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5041 DALLAS HWY STE 703
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-6458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-913-6337
-----------------------------------------------------
Fax | 404-393-7473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5041 DALLAS HWY STE 703
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-6458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-913-6337
-----------------------------------------------------
Fax | 404-393-7473
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | KHADJA HOLMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-913-6337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------