Provider Demographics
NPI:1710215132
Name:NEEDHAM, MICK (MA, MS, BCBA)
Entity Type:Individual
Prefix:
First Name:MICK
Middle Name:
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:MA, MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 BRICK CHURCH PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-2800
Mailing Address - Country:US
Mailing Address - Phone:615-262-7822
Mailing Address - Fax:
Practice Address - Street 1:3203 BRICK CHURCH PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-2800
Practice Address - Country:US
Practice Address - Phone:615-262-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-02-1029103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst