Provider Demographics
NPI:1073833232
Name:WITHHART, LAUREN T (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:T
Last Name:WITHHART
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 NACOOCHEE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3133
Mailing Address - Country:US
Mailing Address - Phone:678-249-5779
Mailing Address - Fax:
Practice Address - Street 1:218 NACOOCHEE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3133
Practice Address - Country:US
Practice Address - Phone:678-249-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-05-2318103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst