Provider Demographics
NPI:1770300477
Name:SUNRISE BEHAVIORAL THERAPY LLC
Entity type:Organization
Organization Name:SUNRISE BEHAVIORAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BCBA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:EMILIE
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:209-597-6489
Mailing Address - Street 1:20 HINSON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6115
Mailing Address - Country:US
Mailing Address - Phone:209-597-6489
Mailing Address - Fax:
Practice Address - Street 1:20 HINSON ST STE 5
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6115
Practice Address - Country:US
Practice Address - Phone:209-597-6489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003271067CMedicaid