Healthcare Provider Details

I. General information

NPI: 1427633783
Provider Name (Legal Business Name): FULL SPECTRUM ABA THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MEADOW AVE
CRAWFORDSVILLE IN
47933-2718
US

IV. Provider business mailing address

407 MEADOW AVE
CRAWFORDSVILLE IN
47933-2718
US

V. Phone/Fax

Practice location:
  • Phone: 317-318-4352
  • Fax:
Mailing address:
  • Phone: 317-318-4352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: LAUREN LONG
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA
Phone: 317-318-4352