Healthcare Provider Details

I. General information

NPI: 1477992758
Provider Name (Legal Business Name): ABA 4 AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WALTER HILL RD
MONT VERNON NH
03057-1528
US

IV. Provider business mailing address

6 WALTER HILL RD
MONT VERNON NH
03057-1528
US

V. Phone/Fax

Practice location:
  • Phone: 603-732-3415
  • Fax:
Mailing address:
  • Phone: 603-732-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-10-7436
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01003313
License Number StateNH

VIII. Authorized Official

Name: PERRY OLSEN
Title or Position: OWNER
Credential:
Phone: 603-732-3415