Provider Demographics
NPI:1992074934
Name:MACHOSE, MICHAEL P (BCBA, LPA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:MACHOSE
Suffix:
Gender:M
Credentials:BCBA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10926 S TRYON ST STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4154
Mailing Address - Country:US
Mailing Address - Phone:704-931-8870
Mailing Address - Fax:866-313-7602
Practice Address - Street 1:10926 S TRYON ST STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4154
Practice Address - Country:US
Practice Address - Phone:704-931-8870
Practice Address - Fax:866-313-7602
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103TS0200X
NC4297103TB0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487904041OtherNPPES
NC6107742Medicaid