Provider Demographics
NPI:1962835579
Name:BORNEMISS, SARAH (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:BORNEMISS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 TOWNE LAKE PKWY
Mailing Address - Street 2:SUITE 116-158
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5520
Mailing Address - Country:US
Mailing Address - Phone:770-508-5187
Mailing Address - Fax:180-088-3926
Practice Address - Street 1:2295 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 116-158
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5520
Practice Address - Country:US
Practice Address - Phone:770-508-5187
Practice Address - Fax:180-088-3926
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-12-10126103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst