Provider Demographics
NPI:1831733583
Name:MEHLBAUM, BETH A (BCBA)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:MEHLBAUM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2984
Mailing Address - Country:US
Mailing Address - Phone:608-756-5555
Mailing Address - Fax:608-314-2442
Practice Address - Street 1:580 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2984
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-314-2442
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI323-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100067992Medicaid