Basic Information
| Provider Information | |||||||||
| NPI: | 1487904041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA BEHAVIORAL GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
| FaxNumber: | 8888494249 | ||||||||
| Practice Location | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
| FaxNumber: | 8888494249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2012 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | MACHOSE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER/BEHAVIOR ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 7049318870 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CAS, BCBA, LPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4297 | NC | Y | Agencies | Community/Behavioral Health |
No ID Information.