Provider Demographics
NPI:1205380920
Name:MAGNOLIA ABA INSTITUTE, INC
Entity Type:Organization
Organization Name:MAGNOLIA ABA INSTITUTE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA
Authorized Official - Phone:615-613-1869
Mailing Address - Street 1:7944 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-6667
Mailing Address - Country:US
Mailing Address - Phone:615-613-1869
Mailing Address - Fax:931-443-0203
Practice Address - Street 1:279 CLEAR SKY CT
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5946
Practice Address - Country:US
Practice Address - Phone:615-613-1869
Practice Address - Fax:931-443-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000856685103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty