Basic Information
| Provider Information | |||||||||
| NPI: | 1790043370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NALLEY | ||||||||
| FirstName: | ASHTON | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.S., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6298 VETERANS PKWY STE 9B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319096281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065717771 | ||||||||
| FaxNumber: | 7065717765 | ||||||||
| Practice Location | |||||||||
| Address1: | 6450 SPALDING DR STE B | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CORNERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300924650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8336288476 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 110026265 | 05 | GA | MEDICAID |