Healthcare Provider Details

I. General information

NPI: 1770249559
Provider Name (Legal Business Name): SHAPE BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 MARION RD
COLUMBUS OH
43207-2141
US

IV. Provider business mailing address

1316 MARION RD
COLUMBUS OH
43207-2141
US

V. Phone/Fax

Practice location:
  • Phone: 614-754-6630
  • Fax:
Mailing address:
  • Phone: 614-754-6630
  • 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
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALEX KISS
Title or Position: DIRECTOR
Credential:
Phone: 423-281-4333