Provider Demographics
NPI:1760850812
Name:AIJAZ, TEBA
Entity Type:Individual
Prefix:
First Name:TEBA
Middle Name:
Last Name:AIJAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 ASHFORD DUNWOODY RD NE UNIT 1431
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1618
Mailing Address - Country:US
Mailing Address - Phone:312-881-9044
Mailing Address - Fax:
Practice Address - Street 1:833 HURRICANE SHOALS RD NE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4821
Practice Address - Country:US
Practice Address - Phone:833-628-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-07
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IL1-21-56947103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst