Healthcare Provider Details

I. General information

NPI: 1992130017
Provider Name (Legal Business Name): FLY BEHAVIORAL SERVICES, LICENSED BEHAVIOR ANALYST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 W 118TH ST APT 1D
NEW YORK NY
10026-1855
US

IV. Provider business mailing address

111 W 117TH ST APT 3
NEW YORK NY
10026-1589
US

V. Phone/Fax

Practice location:
  • Phone: 646-524-5984
  • Fax:
Mailing address:
  • Phone: 646-524-5984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA WONG
Title or Position: FOUNDER
Credential: BCBA, LBA-NY
Phone: 646-524-5984