Provider Demographics
NPI:1114673357
Name:BROWN, MARY MADISON (MS, BCBA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MADISON
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 BAXTER ST APT 308
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3777
Mailing Address - Country:US
Mailing Address - Phone:251-363-3835
Mailing Address - Fax:
Practice Address - Street 1:2053 EXPERIMENT STATION RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-5326
Practice Address - Country:US
Practice Address - Phone:334-792-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22-204355106S00000X
1-24-76894103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL22-204355Other22-204355