Healthcare Provider Details

I. General information

NPI: 1760011555
Provider Name (Legal Business Name): A BCBA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 QUAIL RIDGE DR APT 10
WASHINGTON UT
84780-1483
US

IV. Provider business mailing address

236 QUAIL RIDGE DR APT 10
WASHINGTON UT
84780-1483
US

V. Phone/Fax

Practice location:
  • Phone: 909-276-1072
  • Fax:
Mailing address:
  • Phone: 909-276-1072
  • 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: ASHLEY ROSE KOONTZ
Title or Position: OWNER/BCBA
Credential: M.ED, BCBA, LBA
Phone: 909-276-1072