Healthcare Provider Details

I. General information

NPI: 1346920162
Provider Name (Legal Business Name): GOLD HEART ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 12/21/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MACINTOSH CT
JACKSON NJ
08527-1176
US

IV. Provider business mailing address

5 MACINTOSH CT
JACKSON NJ
08527-1176
US

V. Phone/Fax

Practice location:
  • Phone: 631-507-7643
  • Fax:
Mailing address:
  • Phone: 631-507-7643
  • 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
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: YEHOUSHUA TYBERG
Title or Position: OWNER
Credential:
Phone: 631-507-7643