MEDICARE: ELIZABETH COUNTRYMAN BCBA, LBA

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	106S00000X	Behavior Technician	RBT-19-94698	NC
2	103K00000X	Behavior Analyst	1-22-60599	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-22-60599	OTHER	SC	BACB CERTIFICATION

General Provider Information

NPI Number	:	1376194225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH COUNTRYMAN BCBA, LBA

Provider Business Mailing Address
First Line	:	6705 WHITE HORSE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-2503
Country	:	US
Telephone Number	:	704-654-8599
Fax Number	:	980-938-6088

Provider Business Practice Location Address
First Line	:	6705 WHITE HORSE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-2503
Country	:	US
Telephone Number	:	704-654-8599
Fax Number	:	980-938-6088

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

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	07/29/2025

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