Provider Demographics
NPI:1568943025
Name:THOMASON, MARY NICOLE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:NICOLE
Last Name:THOMASON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1465 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4719
Mailing Address - Country:US
Mailing Address - Phone:601-352-7784
Mailing Address - Fax:769-230-2863
Practice Address - Street 1:1531 HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7469
Practice Address - Country:US
Practice Address - Phone:601-707-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-27492103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst