MEDICARE: MANKATO FULL SPECTRUM ABA

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	:	1356127997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANKATO FULL SPECTRUM ABA

Provider Business Mailing Address
First Line	:	1821 BASSETT DR STE 103
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6223
Country	:	US
Telephone Number	:	507-351-1034
Fax Number	:	507-299-9887

Provider Business Practice Location Address
First Line	:	1821 BASSETT DR STE 103
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6223
Country	:	US
Telephone Number	:	507-900-5501
Fax Number	:	507-299-9887

Authorized Official
Title or Position	:	MANAGER
Name	:	ANIS ABDULLAHI
Credential	:
Telephone Number	:	507-900-5501

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	03/23/2026

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