=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982073672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEXT STEP SOUTHWEST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1835 E GUADALUPE RD SUITE 103
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-3277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-659-5456
-----------------------------------------------------
Fax | 480-838-1828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1835 E GUADALUPE RD SUITE 103
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-3277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-659-5456
-----------------------------------------------------
Fax | 480-838-1828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/FOUNDER
-----------------------------------------------------
Name | MRS. CORINNA NDOLO
-----------------------------------------------------
Credential | M.ED, BCBA, LBA
-----------------------------------------------------
Telephone | 480-659-5456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BA-193
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------