Healthcare Provider Details

I. General information

NPI: 1912592130
Provider Name (Legal Business Name): MARIN AUTISM INTERVENTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 EMMANUEL WAY LN
WEBSTER KY
40176-5037
US

IV. Provider business mailing address

228 EMMANUEL WAY LN
WEBSTER KY
40176-5037
US

V. Phone/Fax

Practice location:
  • Phone: 270-883-5547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
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

VIII. Authorized Official

Name: SHANNON PRIDDY-MARIN
Title or Position: OWNER
Credential:
Phone: 270-883-5547