Provider Demographics
NPI:1003463670
Name:MINTON, MARY ELIZABETH (MS, BCBA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MINTON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 BRAWLEY SCHOOL RD #104, MOORESVILLE, NC 28117
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6876
Mailing Address - Country:US
Mailing Address - Phone:704-703-8588
Mailing Address - Fax:
Practice Address - Street 1:1835 DAVIE AVE STE 413
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3578
Practice Address - Country:US
Practice Address - Phone:704-572-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2024-08-15
Deactivation Date:2024-05-25
Deactivation Code:
Reactivation Date:2024-06-07
Provider Licenses
StateLicense IDTaxonomies
1-24-73157103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst