Provider Demographics
NPI:1124614813
Name:WHITE, MARA FELICE (BCBA)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:FELICE
Last Name:WHITE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7465 HIGHTOWER CIR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-3174
Mailing Address - Country:US
Mailing Address - Phone:215-518-3709
Mailing Address - Fax:
Practice Address - Street 1:7465 HIGHTOWER CIR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-3174
Practice Address - Country:US
Practice Address - Phone:215-518-3709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA251S00000X
GA1-21-49657103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003246117Medicaid
GA003246117Medicaid