MEDICARE: POSITIVE BEHAVIOR SUPPORT

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

General Provider Information

NPI Number	:	1912609892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POSITIVE BEHAVIOR SUPPORT

Provider Business Mailing Address
First Line	:	1001 MASON TUCKER DR APT I70
Second Line	:
City	:	SMYRNA
State	:	TN
Zip	:	37167-5615
Country	:	US
Telephone Number	:	424-542-9922
Fax Number	:

Provider Business Practice Location Address
First Line	:	2717 EDGE O LAKE DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37217-4054
Country	:	US
Telephone Number	:	615-854-7535
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	MS. LATOYA IMAGILL
Credential	:
Telephone Number	:	185-583-2672

Provider Enumeration Date	:	03/21/2023
Last Update Date	:	03/21/2023

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