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General NPI Number Information
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NPI Number | 1396335832
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Entity Type | Organization
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Legal Business Name | ABA AT THE BAY LLC
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Dates
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Enumeration Date | 01/19/2021
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Last Update Date | 01/19/2021
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Provider Practice Location Address
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Address Line | 4636 CORONET AVE UNIT A
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-1404
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Country | US
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Telephone | 757-576-9361
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Fax |
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Provider Business Mailing Address
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Address Line | 4636 CORONET AVE UNIT A
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-1404
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Country | US
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Telephone | 757-576-9361
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN FRIES
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Credential | MS, BCBA, LBA
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Telephone | 757-576-9361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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