Provider Demographics
NPI:1336593177
Name:STAUB, MARY (BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STAUB
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:HANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:814 EVOLVE WAY # 3-310
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37915-2383
Mailing Address - Country:US
Mailing Address - Phone:260-413-8744
Mailing Address - Fax:
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4720
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11520854103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst