Provider Demographics
NPI:1750751434
Name:MIDSOUTH BEHAVIOR CLINIC
Entity type:Organization
Organization Name:MIDSOUTH BEHAVIOR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:MCCORD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA
Authorized Official - Phone:901-497-0384
Mailing Address - Street 1:12482 MAGNOLIA BEND DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-7046
Mailing Address - Country:US
Mailing Address - Phone:901-497-0384
Mailing Address - Fax:866-823-6014
Practice Address - Street 1:12482 MAGNOLIA BEND DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-7046
Practice Address - Country:US
Practice Address - Phone:901-497-0384
Practice Address - Fax:866-823-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2500733Medicaid