=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902573496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EIGHTY-TWENTY LEARNING FOR ASD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2021
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 COUNTY ROAD 375
-----------------------------------------------------
City | BONO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72416-7661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-926-9259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 COUNTY ROAD 375
-----------------------------------------------------
City | BONO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72416-7661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-926-9259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/BCBA
-----------------------------------------------------
Name | LESLIE GLIDEWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-926-9259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------