Provider Demographics
NPI:1609507961
Name:THWEATT ADVANCED BEHAVIOR ASSOCIATES
Entity type:Organization
Organization Name:THWEATT ADVANCED BEHAVIOR ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:RENEE THOMAS
Authorized Official - Last Name:THWEATT-BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:731-614-3101
Mailing Address - Street 1:708 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1350
Mailing Address - Country:US
Mailing Address - Phone:731-614-3101
Mailing Address - Fax:228-300-2113
Practice Address - Street 1:708 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1350
Practice Address - Country:US
Practice Address - Phone:731-614-3101
Practice Address - Fax:228-300-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000000623OtherTENNESSEE DEPARTMENT OF HEALTH
MS200005OtherMISSISSIPPI AUTISM BOARD
MS06888361Medicaid
ALLBA0000000627OtherALABAMA BEHAVIOR ANALYST LICENSING BOARD