Healthcare Provider Details

I. General information

NPI: 1457060071
Provider Name (Legal Business Name): SUPPORTIVE CARE ABA NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S WHITE ST STE 150
WAKE FOREST NC
27587-2773
US

IV. Provider business mailing address

104 S WHITE ST STE 150
WAKE FOREST NC
27587-2773
US

V. Phone/Fax

Practice location:
  • Phone: 317-936-1240
  • Fax:
Mailing address:
  • Phone:
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RUBEN KESHERIM
Title or Position: MEMBER
Credential:
Phone: 317-936-1240