Provider Demographics
NPI:1992308605
Name:SOUTH GEORGIA BEHAVIOR ASSOCIATES
Entity type:Organization
Organization Name:SOUTH GEORGIA BEHAVIOR ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, BCBA,
Authorized Official - Prefix:
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:MINGO
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:850-345-8336
Mailing Address - Street 1:113 SOUTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31639
Mailing Address - Country:US
Mailing Address - Phone:850-345-8336
Mailing Address - Fax:
Practice Address - Street 1:113 SOUTHSIDE DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639
Practice Address - Country:US
Practice Address - Phone:850-345-8336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003204507AMedicaid
GA003277334AMedicaid