Provider Demographics
NPI:1790239556
Name:WATHEN, ELIZABETH (BCBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WATHEN
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 1:1720 PEACHTREE ST. NE
Mailing Address - Street 2:UNIT 510
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309
Mailing Address - Country:US
Mailing Address - Phone:989-397-2256
Mailing Address - Fax:
Practice Address - Street 1:2329 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4719
Practice Address - Country:US
Practice Address - Phone:770-637-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2024-02-01
Deactivation Date:2022-01-04
Deactivation Code:
Reactivation Date:2022-02-28
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 247200000X
MI7401001502103K00000X
GA1-21-49910103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other