MEDICARE: NEXT PHASE BEHAVIORAL SOLUTIONS 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	:	1770046880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEXT PHASE BEHAVIORAL SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	9637 HOLLOW PINE DR
Second Line	:
City	:	MIDLAND
State	:	GA
Zip	:	31820-6314
Country	:	US
Telephone Number	:	706-905-5525
Fax Number	:

Provider Business Practice Location Address
First Line	:	9637 HOLLOW PINE DR
Second Line	:
City	:	MIDLAND
State	:	GA
Zip	:	31820-6314
Country	:	US
Telephone Number	:	706-905-5525
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIOR THERAPIST
Name	:	CARLINE DIE
Credential	:	BCBA
Telephone Number	:	706-905-5525

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	04/08/2019

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