MEDICARE: AUTISM BRAIN ALTERNATIVES, INC

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	1084008	IN

General Provider Information

NPI Number	:	1477863520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTISM BRAIN ALTERNATIVES, INC

Provider Business Mailing Address
First Line	:	614 E BOULEVARD
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-2271
Country	:	US
Telephone Number	:	765-461-1245
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 E BOULEVARD
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-2271
Country	:	US
Telephone Number	:	765-461-1245
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. CLINTON PAUL
Credential	:
Telephone Number	:	765-461-1245

Provider Enumeration Date	:	10/07/2010
Last Update Date	:	01/12/2016

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