MEDICARE: ADVANTAGE ABA & AUTISM THERAPY GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1043179260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE ABA & AUTISM THERAPY GROUP LLC

Provider Business Mailing Address
First Line	:	2114 GROVE TERRACE LN
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-2114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2114 GROVE TERRACE LN
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-2114
Country	:	US
Telephone Number	:	832-671-9969
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DAVIQUE HUMPHREY
Credential	:
Telephone Number	:	832-671-9969

Provider Enumeration Date	:	01/22/2026
Last Update Date	:	01/22/2026

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