Healthcare Provider Details

I. General information

NPI: 1407399660
Provider Name (Legal Business Name): AUTISM BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RESERVE RD STE F300
DANBURY CT
06810
US

IV. Provider business mailing address

100 RESERVE RD STE F300
DANBURY CT
06810
US

V. Phone/Fax

Practice location:
  • Phone: 203-429-5318
  • Fax: 203-628-4388
Mailing address:
  • Phone: 203-429-5318
  • Fax: 203-628-4388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: JESSIE WONG
Title or Position: CLINICAL DIRECTOR
Credential: BCBA, LBA
Phone: 203-884-1268