Provider Demographics
NPI:1770084279
Name:HANCOCK, MARY (RBT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 WILMA RUDOLPH BLVD.
Mailing Address - Street 2:SUITE F #259
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:931-538-1460
Mailing Address - Fax:
Practice Address - Street 1:2250 WILMA RUDOLPH BLVD.
Practice Address - Street 2:SUITE F #259
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-538-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-15-05345106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-15-05345OtherBACB
1-21-46953OtherBACB