Healthcare Provider Details

I. General information

NPI: 1205690203
Provider Name (Legal Business Name): IMPACT LICENSED BEHAVIOR ANALYSIS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 STOCKTON ST APT 2B
BROOKLYN NY
11206-5688
US

IV. Provider business mailing address

134 STOCKTON ST APT 2B
BROOKLYN NY
11206-5688
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-0007
  • Fax:
Mailing address:
  • Phone:
  • 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: JUDY ROTH
Title or Position: CEO
Credential: MSED, BCBA, LBA
Phone: 718-963-0007