Healthcare Provider Details

I. General information

NPI: 1154805315
Provider Name (Legal Business Name): BLUEBIRD ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2018
Last Update Date: 01/06/2021
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8222 WESTMINSTER RD
ELKINS PARK PA
19027-1409
US

IV. Provider business mailing address

8222 WESTMINSTER RD
ELKINS PARK PA
19027-1409
US

V. Phone/Fax

Practice location:
  • Phone: 215-586-1865
  • Fax:
Mailing address:
  • Phone: 215-586-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN DEIKMAN
Title or Position: MANAGING MEMBER
Credential: MS, BCBA, LBS
Phone: 215-586-1865