MEDICARE: SPECTRUM SPROUTS ABA THERAPY

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	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician

General Provider Information

NPI Number	:	1508713017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM SPROUTS ABA THERAPY

Provider Business Mailing Address
First Line	:	5811 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5811 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2138
Country	:	US
Telephone Number	:	267-808-5801
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	REGINALD BULLOCK
Credential	:
Telephone Number	:	267-808-5801

Provider Enumeration Date	:	03/13/2026
Last Update Date	:	03/13/2026

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