MEDICARE: HOMEGROWN ABA, 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	:	1154043834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMEGROWN ABA, LLC

Provider Business Mailing Address
First Line	:	3560 VERGER LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-2512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3560 VERGER LN
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-2512
Country	:	US
Telephone Number	:	440-223-9161
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	MICHAEL GOLDBERG
Credential	:
Telephone Number	:	440-223-9161

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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