MEDICARE: KENNETH DAVID CULBERTSON 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	103TB0200X	Cognitive & Behavioral Psychologist		FL
2	106S00000X	Behavior Technician	RBT-18-73414	FL
3	103K00000X	Behavior Analyst	1-25-79013	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841763422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH DAVID CULBERTSON BCBA

Provider Business Mailing Address
First Line	:	108 LOWER MILL CREEK RD
Second Line	:
City	:	ROCKY FACE
State	:	GA
Zip	:	30740-3202
Country	:	US
Telephone Number	:	618-309-2681
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 GEORGETOWN RD NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3553
Country	:	US
Telephone Number	:	423-464-6020
Fax Number	:

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

Provider Enumeration Date	:	01/07/2019
Last Update Date	:	05/13/2026

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