Provider Demographics
NPI:1497116834
Name:KNOX, STEPHANIE (BCBA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KNOX
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 HEATHERDOWN WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3592
Mailing Address - Country:US
Mailing Address - Phone:404-565-6029
Mailing Address - Fax:
Practice Address - Street 1:505 HEATHERDOWN WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3592
Practice Address - Country:US
Practice Address - Phone:404-565-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01-14-17610103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13604699OtherCAQH