Healthcare Provider Details

I. General information

NPI: 1427619626
Provider Name (Legal Business Name): COLLABORATIVE ABA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 SAYBROOK RD UNIT B4
MIDDLETOWN CT
06457-4739
US

IV. Provider business mailing address

770 SAYBROOK RD UNIT B4
MIDDLETOWN CT
06457-4739
US

V. Phone/Fax

Practice location:
  • Phone: 860-421-4052
  • Fax: 860-421-4053
Mailing address:
  • Phone: 860-421-4052
  • Fax: 860-421-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALISHA SIMPSON-WATT
Title or Position: DIRECTOR/OWNER
Credential: LCSW, BCBA, LBA
Phone: 860-740-2547