MEDICARE: LYSA MARI HARAWAY BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	LBA000127	GA

General Provider Information

NPI Number	:	1164795738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYSA MARI HARAWAY BCBA

Provider Business Mailing Address
First Line	:	41769 ENTERPRISE CIR N STE 104
Second Line	:
City	:	TEMECULA
State	:	CA
Zip	:	92590-5626
Country	:	US
Telephone Number	:	951-253-3766
Fax Number	:

Provider Business Practice Location Address
First Line	:	290 HIGHWAY 314
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7813
Country	:	US
Telephone Number	:	404-994-7727
Fax Number	:	404-994-7728

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	01/21/2026

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