=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649744525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENCE BEHAVIOR SOLUTIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2019
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2451B US HIGHWAY 17
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-560-6622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5203 MARYLAND WAY STE 104
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-560-6622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, FINANCE
-----------------------------------------------------
Name | MR. SPENCER CUMMINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-560-6622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------