Provider Demographics
NPI:1619492253
Name:BECKHOM BEHAVIORAL CONSULTING, LLC
Entity type:Organization
Organization Name:BECKHOM BEHAVIORAL CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WILBURN-BECKHOM
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:229-439-9951
Mailing Address - Street 1:PO BOX 51293
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31703-1293
Mailing Address - Country:US
Mailing Address - Phone:229-439-9951
Mailing Address - Fax:229-439-9553
Practice Address - Street 1:1509 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3647
Practice Address - Country:US
Practice Address - Phone:229-439-9951
Practice Address - Fax:229-439-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 106S00000X
1-03-1465103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003183174AMedicaid
GA003179879BMedicaid
GA003179879CMedicaid