Healthcare Provider Details

I. General information

NPI: 1649805581
Provider Name (Legal Business Name): GROWTH STREET ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WALNUT PKWY APT 2
MONTCLAIR NJ
07042-4958
US

IV. Provider business mailing address

9220 78TH ST
WOODHAVEN NY
11421-2904
US

V. Phone/Fax

Practice location:
  • Phone: 347-463-6267
  • Fax:
Mailing address:
  • Phone: 347-463-6267
  • 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 Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: JASMINE WRIGHT
Title or Position: OWNER
Credential:
Phone: 347-247-4070