Healthcare Provider Details

I. General information

NPI: 1538771209
Provider Name (Legal Business Name): SIGNATURE MA LICENSED APPLIED BEHAVIOR ANALYSIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2020
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 MADISON AVE FL 12
NEW YORK NY
10017-6379
US

IV. Provider business mailing address

295 MADISON AVE FL 12
NEW YORK NY
10017-6379
US

V. Phone/Fax

Practice location:
  • Phone: 917-310-5187
  • Fax:
Mailing address:
  • Phone: 917-310-5187
  • 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: SOPHIA MA
Title or Position: PRESIDENT
Credential: LBA, BCBA
Phone: 917-310-5187