Basic Information
| Provider Information | |||||||||
| NPI: | 1154683381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUND | ||||||||
| FirstName: | COBY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHD, BCBA-D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 PERIMETER CENTER EAST | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667505554 | ||||||||
| FaxNumber: | 8662014406 | ||||||||
| Practice Location | |||||||||
| Address1: | 53 PERIMETER CENTER EAST | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667505554 | ||||||||
| FaxNumber: | 8662014406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2012 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 272165530A | 05 | GA | MEDICAID |