MEDICARE: ABA SUPER KIDS 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	:	1073266490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABA SUPER KIDS LLC

Provider Business Mailing Address
First Line	:	1635 RENAISSANCE COMMONS BLVD APT 2109
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8376
Country	:	US
Telephone Number	:	561-891-0399
Fax Number	:

Provider Business Practice Location Address
First Line	:	1635 RENAISSANCE COMMONS BLVD APT 2109
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8376
Country	:	US
Telephone Number	:	561-891-0399
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARIA DAVYDOVA
Credential	:	BCBA
Telephone Number	:	561-891-0399

Provider Enumeration Date	:	01/27/2022
Last Update Date	:	01/27/2022

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