Healthcare Provider Details

I. General information

NPI: 1437431624
Provider Name (Legal Business Name): FUNDAMENTAL BEHAVIOR SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 N FREDERICK AVE # 345
GAITHERSBURG MD
20877-2504
US

IV. Provider business mailing address

554 N FREDERICK AVE # 345
GAITHERSBURG MD
20877-2504
US

V. Phone/Fax

Practice location:
  • Phone: 240-361-7178
  • Fax:
Mailing address:
  • Phone: 240-361-7178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8537
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA
Phone: 240-361-7178