Healthcare Provider Details

I. General information

NPI: 1063964930
Provider Name (Legal Business Name): GRANITE STATE ABA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 KEARSARGE RD
NORTH CONWAY NH
03860-5331
US

IV. Provider business mailing address

PO BOX 955
GLEN NH
03838-0955
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-6616
  • Fax: 603-356-6617
Mailing address:
  • Phone: 603-356-6616
  • Fax: 603-356-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ARIANA LOPEZ
Title or Position: ADMIN
Credential:
Phone: 714-334-3839