Basic Information
| Provider Information | |||||||||
| NPI: | 1952817157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELCH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | MA, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9230 OLD LORRAINE RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395036059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012555264 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9230 OLD LORRAINE RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012555264 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2017 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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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 | LA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | MS | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.