Healthcare Provider Details

I. General information

NPI: 1225574544
Provider Name (Legal Business Name): MOUNTAINSIDE BEHAVIOR ANALYSIS SERVICES, LCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 THISTLE LN
DAVIS WV
26260-1104
US

IV. Provider business mailing address

25 THISTLE LN
DAVIS WV
26260-1104
US

V. Phone/Fax

Practice location:
  • Phone: 304-801-3258
  • Fax: 304-362-0025
Mailing address:
  • Phone: 304-801-3258
  • Fax: 304-362-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0133000550
License Number StateVA

VIII. Authorized Official

Name: ELIZABETH SIMONS
Title or Position: OWNER
Credential: BCBA
Phone: 304-851-6643