Healthcare Provider Details

I. General information

NPI: 1518779578
Provider Name (Legal Business Name): LITTLE GREEN TUGBOAT LICENSED BEHAVIOR ANALYSIS SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 19TH ST # 1
ASTORIA NY
11102-3442
US

IV. Provider business mailing address

3811 DITMARS BLVD STE 2282
ASTORIA NY
11105-2176
US

V. Phone/Fax

Practice location:
  • Phone: 310-428-6102
  • Fax:
Mailing address:
  • Phone: 310-428-6102
  • 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

VIII. Authorized Official

Name: STEPHANIE KOH
Title or Position: FOUNDER, DIRECTOR
Credential: MA, BCBA, LBA
Phone: 310-428-6102