=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265912919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABA WEISSENBERG ELITE BEHAVIORAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2018
-----------------------------------------------------
Last Update Date | 07/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4930 CAMPUS DR
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-995-3615
-----------------------------------------------------
Fax | 833-275-1309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1519
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83680-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-995-3615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | LAURA DICKERSON
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 208-995-3615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-14-10119
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1-14-10119
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------