MEDICARE: MARRY ST HOME 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	:	1326999061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARRY ST HOME ABA LLC

Provider Business Mailing Address
First Line	:	400 RELLA BLVD STE 165
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-8114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 RELLA BLVD STE 165
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-4266
Country	:	US
Telephone Number	:	845-445-6777
Fax Number	:

Authorized Official
Title or Position	:	TEAM LEAD
Name	:	KATHLENE L
Credential	:
Telephone Number	:	845-445-6777

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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