1003463670 NPI number — MARY ELIZABETH MINTON MS, BCBA

Table of content: MARY ELIZABETH MINTON MS, BCBA (NPI 1003463670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003463670 NPI number — MARY ELIZABETH MINTON MS, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINTON
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003463670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/25/2024
NPI Reactivation Date:
06/07/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
647 BRAWLEY SCHOOL RD #104, MOORESVILLE, NC 28117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-6876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-703-8588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 DAVIE AVE STE 413
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-3578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-572-3810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-24-73157 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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