Healthcare Provider Details

I. General information

NPI: 1932867322
Provider Name (Legal Business Name): SHAPE BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SOUTH INDIANA AVE
BLOOMINGTON IN
47405
US

IV. Provider business mailing address

722 S LIBERTY ST STE 218
MUNCIE IN
47305-2346
US

V. Phone/Fax

Practice location:
  • Phone: 423-281-4333
  • Fax:
Mailing address:
  • Phone: 423-281-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ALEX KISS
Title or Position: DIRECTOR
Credential:
Phone: 423-281-4333