Provider Demographics
NPI:1356081863
Name:WELDON, MARY AULTMAN (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AULTMAN
Last Name:WELDON
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FONTAINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5618
Mailing Address - Country:US
Mailing Address - Phone:403-326-3478
Mailing Address - Fax:
Practice Address - Street 1:402 LEGACY PARK
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4315
Practice Address - Country:US
Practice Address - Phone:769-233-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS200052103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst