=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407576986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA GRACE HUFFMAN RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5125 DECATUR BLVD
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46241-9570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-618-4041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 LENNOX RD
-----------------------------------------------------
City | POLAND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47868-7087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-201-5136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BACB619342
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | BACB619342
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------