Basic Information
| Provider Information | |||||||||
| NPI: | 1548627904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEARSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MOORE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MAT, BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51322 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421025622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707779283 | ||||||||
| Practice Location | |||||||||
| Address1: | 3115 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292051856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037913222 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-04-1371 | SC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.