Healthcare Provider Details

I. General information

NPI: 1760995518
Provider Name (Legal Business Name): ACHIEVE BEYOND LICENSED BEHAVIOR ANALYST SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4822
US

IV. Provider business mailing address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4822
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax: 631-385-7795
Mailing address:
  • Phone: 631-385-7780
  • Fax: 631-385-7795

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: SHANNON BUTERA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 631-385-7780