Healthcare Provider Details

I. General information

NPI: 1598477879
Provider Name (Legal Business Name): BASELINE LOGIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 S PARK RIDGE RD # 102
BLOOMINGTON IN
47401-8589
US

IV. Provider business mailing address

4101 E 3RD ST
BLOOMINGTON IN
47401-5539
US

V. Phone/Fax

Practice location:
  • Phone: 812-747-9384
  • Fax: 513-278-5465
Mailing address:
  • Phone: 812-747-9384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SARA ALLYN SHRIVASTAV
Title or Position: CEO
Credential: BCBA
Phone: 812-747-9384