=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699258046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED BEHAVIOR SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2018
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1579 SAM SNEAD HWY
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24445-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-969-6493
-----------------------------------------------------
Fax | 888-877-7879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1579 SAM SNEAD HWY
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24445-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-969-6493
-----------------------------------------------------
Fax | 888-877-7879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR ANALYST
-----------------------------------------------------
Name | MELINDA HEMP GARDZINSKI
-----------------------------------------------------
Credential | BCBA/LBA
-----------------------------------------------------
Telephone | 540-969-6493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------