Basic Information
| Provider Information | |||||||||
| NPI: | 1992074934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACHOSE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | BCBA, LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049318870 | ||||||||
| FaxNumber: | 8663137602 | ||||||||
| Practice Location | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049318870 | ||||||||
| FaxNumber: | 8663137602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2011 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103TB0200X | 4297 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TS0200X | N | Behavioral Health & Social Service Providers | Psychologist | School | 103T00000X | 4297 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1487904041 | 01 | NC | NPPES | OTHER | 6107742 | 05 | NC | MEDICAID |