Healthcare Provider Details

I. General information

NPI: 1962019406
Provider Name (Legal Business Name): NLS ABA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 ROUTE 315
PLAINS PA
18702
US

IV. Provider business mailing address

1086 ROUTE 315
PLAINS PA
18702
US

V. Phone/Fax

Practice location:
  • Phone: 570-823-7761
  • Fax: 570-822-8033
Mailing address:
  • Phone: 570-823-7761
  • Fax: 570-822-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANE MITERKO
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 570-823-7761