MEDICARE: FUNCTIONAL BEHAVIOR INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1134711393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL BEHAVIOR INSTITUTE

Provider Business Mailing Address
First Line	:	5248 PALM PINNACLE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-5682
Country	:	US
Telephone Number	:	307-575-2044
Fax Number	:

Provider Business Practice Location Address
First Line	:	5248 PALM PINNACLE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-5682
Country	:	US
Telephone Number	:	307-575-2044
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JAMES TIMOTHY CHURCH
Credential	:	BCBA, LBA
Telephone Number	:	307-575-2044

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/09/2021

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