Healthcare Provider Details

I. General information

NPI: 1063141174
Provider Name (Legal Business Name): HEARTLEAF ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 GRIFFIN RD UNIT 106
BANGOR ME
04401-3023
US

IV. Provider business mailing address

396 GRIFFIN RD UNIT 106
BANGOR ME
04401-3023
US

V. Phone/Fax

Practice location:
  • Phone: 207-745-0750
  • Fax:
Mailing address:
  • Phone: 207-745-0750
  • 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 Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JUDY SEALS
Title or Position: NETWORK OPERATIONS DIRECTOR
Credential:
Phone: 207-573-1000