Basic Information
Provider Information | |||||||||
NPI: | 1235887738 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUGHES | ||||||||
FirstName: | CARISSA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TOMS | ||||||||
OtherFirstName: | CARISSA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 560 SYLVAN AVE STE 1110 | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD CLIFFS | ||||||||
State: | NJ | ||||||||
PostalCode: | 076323118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6468736600 | ||||||||
FaxNumber: | 6468594440 | ||||||||
Practice Location | |||||||||
Address1: | 3348 PEACHTREE RD NE STE 700 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303261682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6468706600 | ||||||||
FaxNumber: | 6468594440 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2022 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-22-57548 | GA | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.