Provider Demographics
NPI:1679842629
Name:SELF DISCOVERY
Entity Type:Organization
Organization Name:SELF DISCOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-757-6621
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35631-0161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1143 COUNTY ROAD 413
Practice Address - Street 2:
Practice Address - City:KILLEN
Practice Address - State:AL
Practice Address - Zip Code:35645-7842
Practice Address - Country:US
Practice Address - Phone:256-757-6621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-08-4512103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty