Healthcare Provider Details

I. General information

NPI: 1083500490
Provider Name (Legal Business Name): GOLD HEART ABA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 SMITH AVE UNIT 101
BALTIMORE MD
21209-3610
US

IV. Provider business mailing address

5700 SMITH AVE UNIT 101
BALTIMORE MD
21209-3610
US

V. Phone/Fax

Practice location:
  • Phone: 732-637-9359
  • Fax: 732-719-5787
Mailing address:
  • Phone: 732-637-9359
  • Fax: 732-719-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior 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

VIII. Authorized Official

Name: YEHOUSHUA TYBERG
Title or Position: DIRECTOR
Credential:
Phone: 732-813-5603