=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104613785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEXT GEN ABA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2025
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 BOULEVARD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-852-8078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 THORPE PARK
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-852-8078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RAUDEL LA O
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-852-8078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------