Provider Demographics
NPI:1164066924
Name:FULL SPECTRUM ABA OF MISSISSIPPI LLC
Entity Type:Organization
Organization Name:FULL SPECTRUM ABA OF MISSISSIPPI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STREETMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:813-926-5454
Mailing Address - Street 1:270 TRACE COLONY PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-8810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 TRACE COLONY PARK DR STE B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8810
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty