Healthcare Provider Details

I. General information

NPI: 1396651642
Provider Name (Legal Business Name): LIAM ALLEN GAY RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 SPENCER ST
LOGANSPORT IN
46947-3583
US

IV. Provider business mailing address

11 STONERIDGE DR
LOGANSPORT IN
46947-2444
US

V. Phone/Fax

Practice location:
  • Phone: 574-702-3662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: