=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154110336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTITUDE ABA NC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 BILTMORE AVE FL 3
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28801-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-460-7918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 157 LATCHES LN
-----------------------------------------------------
City | BALA CYNWYD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19004-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-460-7918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | WENDY LAX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-460-7918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------