=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952737595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY C VANDEWEGE BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2013
-----------------------------------------------------
Last Update Date | 11/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 DURHAM PARK WAY
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-2196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-790-8680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 DURHAM PARK WAY
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-2196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-790-8680
-----------------------------------------------------
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 | 11313529
-----------------------------------------------------
License Number State |
-----------------------------------------------------