Healthcare Provider Details

I. General information

NPI: 1063249381
Provider Name (Legal Business Name): FENTON ABA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W SILVER LAKE RD
FENTON MI
48430-2606
US

IV. Provider business mailing address

212 W SILVER LAKE RD
FENTON MI
48430-2606
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-3070
  • Fax:
Mailing address:
  • Phone: 810-629-3070
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: JUAN ALVARADO
Title or Position: PRESIDENT AND CEO
Credential: O.D.
Phone: 810-629-3070