Provider Demographics
NPI:1972255826
Name:MONG, MICHAEL (PHD, BCBA-D, LBA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MONG
Suffix:
Gender:M
Credentials:PHD, BCBA-D, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4309
Practice Address - Country:US
Practice Address - Phone:228-300-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS220004103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst