Healthcare Provider Details

I. General information

NPI: 1427981562
Provider Name (Legal Business Name): PROUD MOMENTS ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4961 TESLA DR
BOWIE MD
20715-4405
US

IV. Provider business mailing address

7724 MAPLE AVE APT 14
TAKOMA PARK MD
20912-5652
US

V. Phone/Fax

Practice location:
  • Phone: 301-329-8155
  • Fax: 301-329-8155
Mailing address:
  • Phone: 240-956-9658
  • 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: MARIELA R SAMUEL
Title or Position: BEHAVIORAL TECH
Credential:
Phone: 240-956-9658