Provider Demographics
NPI:1215472592
Name:MCINTOSH, ELIZABETH LANE (MS, LBA, BCBA)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LANE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:MS, LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242
Mailing Address - Country:US
Mailing Address - Phone:731-336-4492
Mailing Address - Fax:731-407-7058
Practice Address - Street 1:28 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242
Practice Address - Country:US
Practice Address - Phone:731-336-4492
Practice Address - Fax:731-407-7058
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-16-24387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ026631Medicaid