Provider Demographics
NPI:1649780263
Name:WARDEN, MARY WHITNEY (MA BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WHITNEY
Last Name:WARDEN
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:WHITNEY
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2958 ZEB WARREN RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-7241
Mailing Address - Country:US
Mailing Address - Phone:931-644-5263
Mailing Address - Fax:
Practice Address - Street 1:580 S JEFFERSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4672
Practice Address - Country:US
Practice Address - Phone:888-423-2559
Practice Address - Fax:888-423-2559
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ033102Medicaid