Provider Demographics
NPI:1750906822
Name:MCMAHAN, MARISSA EVANS (BCBA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:EVANS
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:545 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2387 HUNTCREST WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8126
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-22-60650103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst