Provider Demographics
NPI:1528669546
Name:GANGIDI, VIDISHA (BCBA)
Entity type:Individual
Prefix:
First Name:VIDISHA
Middle Name:
Last Name:GANGIDI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:815 PARK NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-6200
Mailing Address - Country:US
Mailing Address - Phone:404-943-1070
Mailing Address - Fax:404-943-0890
Practice Address - Street 1:4335 STEVE REYNOLDS BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3362
Practice Address - Country:US
Practice Address - Phone:770-674-5797
Practice Address - Fax:770-864-5338
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-24-76150103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst