=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023772001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR LIFE ABA VA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 02/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 5TH AVE STE 6115
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10118-6002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-215-5311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 5TH AVE STE 6115
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10118-6002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-215-5311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL COUNSEL
-----------------------------------------------------
Name | MARK A YOST JR.
-----------------------------------------------------
Credential | ESQ
-----------------------------------------------------
Telephone | 718-215-5311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------