MEDICARE: SUNRISE ABA OF GEORGIA LLC

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	:	1609504851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE ABA OF GEORGIA LLC

Provider Business Mailing Address
First Line	:	505 SAN MARIN DR STE 100B
Second Line	:
City	:	NOVATO
State	:	CA
Zip	:	94945-1309
Country	:	US
Telephone Number	:	628-250-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4827 OLD NATIONAL HWY STE 10011
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30337-6234
Country	:	US
Telephone Number	:	628-250-7500
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	BRADY KEITH
Credential	:
Telephone Number	:	628-250-7500

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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