Healthcare Provider Details

I. General information

NPI: 1366055121
Provider Name (Legal Business Name): FAMILY TREEHOUSE ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COON DEN RD
HIGHLAND LAKES NJ
07422-2078
US

IV. Provider business mailing address

120 COON DEN RD
HIGHLAND LAKES NJ
07422-2078
US

V. Phone/Fax

Practice location:
  • Phone: 973-617-6705
  • Fax: 201-621-4346
Mailing address:
  • Phone: 973-617-6705
  • Fax: 201-621-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA LEITAO
Title or Position: OWNER
Credential: BCBA
Phone: 973-617-6705