=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861917916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SJ BEHAVIORAL SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2017
-----------------------------------------------------
Last Update Date | 08/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 447 BEACH 126TH ST
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-582-0085
-----------------------------------------------------
Fax | 347-582-0085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 BEACH 126TH ST
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-582-0085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. SAMANTHA ANN JOHNSON
-----------------------------------------------------
Credential | BCBA, MS ED
-----------------------------------------------------
Telephone | 347-582-0085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------