Provider Demographics
NPI:1487904041
Name:DELTA BEHAVIORAL GROUP, PLLC
Entity type:Organization
Organization Name:DELTA BEHAVIORAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/BEHAVIOR ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHOSE
Authorized Official - Suffix:
Authorized Official - Credentials:CAS, BCBA, LPA
Authorized Official - Phone:704-931-8870
Mailing Address - Street 1:10926 S TRYON ST STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4154
Mailing Address - Country:US
Mailing Address - Phone:855-201-5498
Mailing Address - Fax:888-849-4249
Practice Address - Street 1:10926 S TRYON ST STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4154
Practice Address - Country:US
Practice Address - Phone:855-201-5498
Practice Address - Fax:888-849-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4297251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health