MEDICARE: JUNIOR BOOM ABA LLC

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	:	1861194490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUNIOR BOOM ABA LLC

Provider Business Mailing Address
First Line	:	1344 E 24TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-5143
Country	:	US
Telephone Number	:	347-668-9113
Fax Number	:

Provider Business Practice Location Address
First Line	:	1344 E 24TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-5143
Country	:	US
Telephone Number	:	929-466-1305
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SIMCHA BENDET
Credential	:
Telephone Number	:	929-466-1305

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	03/20/2023

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