Healthcare Provider Details

I. General information

NPI: 1740889823
Provider Name (Legal Business Name): INFINITE CHANGES ABA THERAPY & AUTISM SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 COVINGTON WAY STE 5
MEMPHIS TN
38134-5619
US

IV. Provider business mailing address

8481 REGAL BEND DR
OLIVE BRANCH MS
38654-4416
US

V. Phone/Fax

Practice location:
  • Phone: 901-606-5038
  • Fax:
Mailing address:
  • Phone: 901-606-5038
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: FREDRICCA BROCK
Title or Position: BEHAVIOR ANALYST
Credential: BCBA, LBA
Phone: 901-606-5038