Healthcare Provider Details

I. General information

NPI: 1447965280
Provider Name (Legal Business Name): BRIDGE ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ELLIS LOOP
POCOLA OK
74902-2428
US

IV. Provider business mailing address

6502 HILLTOP RD
VAN BUREN AR
72956-7604
US

V. Phone/Fax

Practice location:
  • Phone: 479-650-3802
  • Fax:
Mailing address:
  • Phone: 479-650-3802
  • 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: WILLIAM KEITH MONTGOMERY
Title or Position: OWNER/BCBA
Credential: MS BCBA
Phone: 479-650-3802