Basic Information
Provider Information | |||||||||
NPI: | 1619575255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS | ||||||||
FirstName: | BESS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILNE | ||||||||
OtherFirstName: | BESS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11121 KINGSTON PIKE STE F | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379342864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8338255246 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11121 KINGSTON PIKE STE F | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379342864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8338255246 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2020 | ||||||||
LastUpdateDate: | 12/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BACB615132 | TN | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 106S00000X | RBT-20-139808 | TN | N |   |   |   |   | 103K00000X | 1-21-56556 | TN | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | RBT-20-139808 | 01 | TN | BACB | OTHER |