MEDICARE: MOSE AND GARRISON SISKIN MEMORIAL FOUNDATION

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

General Provider Information

NPI Number	:	1255992319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOSE AND GARRISON SISKIN MEMORIAL FOUNDATION

Provider Business Mailing Address
First Line	:	1101 CARTER ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37402-5017
Country	:	US
Telephone Number	:	423-490-7710
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 ATLANTA ST SE STE 399
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1977
Country	:	US
Telephone Number	:	423-490-7710
Fax Number	:	423-490-7750

Authorized Official
Title or Position	:	DIRECTOR HEALTHCARE ADMINISTRATION
Name	:	STEPHANIE COOPER-WILKES
Credential	:
Telephone Number	:	423-490-7727

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	06/27/2019

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