=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144977174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABC BEHAVIORAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 03/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4610 WILSHIRE LN
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70665-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-884-8892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4610 WILSHIRE LN
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70665-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-884-8892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR ANALYST
-----------------------------------------------------
Name | AMANDA CARLIN
-----------------------------------------------------
Credential | BCBA, LBA
-----------------------------------------------------
Telephone | 337-884-8892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------