MEDICARE: COLLABORATION STATION, 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	:	1528742483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLABORATION STATION, LLC

Provider Business Mailing Address
First Line	:	5405 MURLAND HOLW
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5405 MURLAND HOLW
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1347
Country	:	US
Telephone Number	:	248-755-7846
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KELSEY RUFFIN
Credential	:	M.ES, BCBA,LBA
Telephone Number	:	248-755-7846

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	06/12/2023

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