Basic Information
| Provider Information | |||||||||
| NPI: | 1194441154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUSBAUM | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NUSBAUM | ||||||||
| OtherFirstName: | JULIA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RBT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 504 CLINTON CENTER DRIVE | ||||||||
| Address2: | CBO - SUITE 4300 | ||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390565610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018152005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4400 OLD CANTON RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392115982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018152005 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 220034 | MS | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.