MEDICARE: RADICAL 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1922958180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADICAL ABA, LLC

Provider Business Mailing Address
First Line	:	2459 MAVERICK WAY
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32162-5101
Country	:	US
Telephone Number	:	815-262-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	2459 MAVERICK WAY
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32162-5101
Country	:	US
Telephone Number	:	815-262-8466
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	KATHERINE LYNN PETRUSA
Credential	:	BCBA
Telephone Number	:	815-262-8466

Provider Enumeration Date	:	01/29/2026
Last Update Date	:	01/29/2026

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