| Southside Aba LLC | |
|
1135 Senoia Rd Tyrone GA 30290-1625 | |
| (770) 626-3044 | |
| (470) 200-2269 |
| Full Name | Southside Aba LLC |
|---|---|
| Speciality | Behavior Analyst |
| Location | 1135 Senoia Rd, Tyrone, Georgia |
| Authorized Official Name and Position | Christine Elaine Marrero (CLINICAL DIRECTOR) |
| Authorized Official Contact | 7707076367 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Southside Aba LLC 1135 Senoia Rd Tyrone GA 30290-1625 Ph: (770) 626-3044 | Southside Aba LLC 1135 Senoia Rd Tyrone GA 30290-1625 Ph: (770) 626-3044 |
| NPI Number | 1134759608 |
|---|---|
| Provider Enumeration Date | 01/23/2020 |
| Last Update Date | 01/23/2020 |
| Certification Date | 01/23/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134759608 | NPI | - | NPPES |
| 003218736A | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103K00000X | Behavior Analyst | () | Primary |
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