Provider Demographics
NPI:1033816178
Name:BEHAVIOR MOMENTUM LLC
Entity Type:Organization
Organization Name:BEHAVIOR MOMENTUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DETHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-676-6689
Mailing Address - Street 1:113 ACADIA DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1850
Mailing Address - Country:US
Mailing Address - Phone:706-676-6689
Mailing Address - Fax:
Practice Address - Street 1:113 ACADIA DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1850
Practice Address - Country:US
Practice Address - Phone:706-676-6689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty