Healthcare Provider Details

I. General information

NPI: 1730786807
Provider Name (Legal Business Name): BLAIR AMBER GRANT MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 05/14/2024
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RISE AUTISM THERAPY SERVICES 239 E WINSLOW RD
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

RISE AUTISM THERAPY SERVICES 239 E WINSLOW RD
BLOOMINGTON IN
47401
US

V. Phone/Fax

Practice location:
  • Phone: 812-202-6001
  • Fax: 812-954-0256
Mailing address:
  • Phone: 812-887-4288
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-106721
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA1-23-65449
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: