Provider Demographics
NPI:1194441154
Name:NUSBAUM, JULIA KELLY (RBT)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:KELLY
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:K
Other - Last Name:NUSBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:504 CLINTON CENTER DRIVE
Mailing Address - Street 2:CBO - SUITE 4300
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5610
Mailing Address - Country:US
Mailing Address - Phone:601-815-2005
Mailing Address - Fax:
Practice Address - Street 1:4400 OLD CANTON RD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5982
Practice Address - Country:US
Practice Address - Phone:601-815-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS220034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst