=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558050542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORFUL BREAKTHROUGH IN ABA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2023
-----------------------------------------------------
Last Update Date | 05/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6418 AZUL ST
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78542-0723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-270-9262
-----------------------------------------------------
Fax | 956-394-1288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21750 HARDY OAK BLVD STE 104 PMB 553984
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-270-9262
-----------------------------------------------------
Fax | 956-394-1288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MAYRA A AGUILLON
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 956-270-9262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------