Provider Demographics
NPI:1063883684
Name:POSITIVE IMPACT BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:POSITIVE IMPACT BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:CAVINESS
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:MAED, BCBA
Authorized Official - Phone:901-604-3857
Mailing Address - Street 1:604 WALKER PKWY
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7598
Mailing Address - Country:US
Mailing Address - Phone:901-604-3857
Mailing Address - Fax:877-744-3449
Practice Address - Street 1:604 WALKER PKWY
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-7598
Practice Address - Country:US
Practice Address - Phone:901-604-3857
Practice Address - Fax:877-744-3449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000488Medicaid