Provider Demographics
NPI:1700300795
Name:MATHURIN MEADOWS, NYMPHA J (MED, BCBA)
Entity type:Individual
Prefix:MRS
First Name:NYMPHA
Middle Name:J
Last Name:MATHURIN MEADOWS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2100 RIVERSIDE PKWY
Mailing Address - Street 2:SUITE 128 - 144
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5368
Mailing Address - Country:US
Mailing Address - Phone:800-331-8604
Mailing Address - Fax:800-331-8604
Practice Address - Street 1:11340 LAKEFIELD DR STE 200
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2456
Practice Address - Country:US
Practice Address - Phone:800-331-8604
Practice Address - Fax:800-331-8604
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1700300795Medicaid
GA1205138864Medicaid