=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174411045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHINING MOMENTS MD ABA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6340 SECURITY BLVD STE 1425
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-494-2481
-----------------------------------------------------
Fax | 908-573-9414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6340 SECURITY BLVD STE 1425
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 908-573-9414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RCM
-----------------------------------------------------
Name | BRITTANY MARSHALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-837-7655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------