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General NPI Number Information
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NPI Number | 1154797694
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Entity Type | Organization
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Legal Business Name | WIESNER ABA LLC
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 08/19/2015
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Provider Practice Location Address
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Address Line | 2990 BLACKBURN ST APT 3164
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City | DALLAS
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State | TX
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Zip | 75204-3113
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Country | US
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Telephone | 936-554-1616
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Fax |
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Provider Business Mailing Address
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Address Line | 2990 BLACKBURN ST APT 3164
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City | DALLAS
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State | TX
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Zip | 75204-3113
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Country | US
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Telephone | 936-554-1616
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Fax |
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Authorized Official
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Title or Position | OWNER, FOUNDER
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Name | TAYLOR WIESNER
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Credential | BCBA
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Telephone | 936-554-1616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | TX
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