MEDICARE: BLUE MOUNTAIN 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	:	1598571317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE MOUNTAIN ABA LLC

Provider Business Mailing Address
First Line	:	1308 DINSMORE AVE
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-4753
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 N HIGH SCHOOL RD STE G
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-1100
Country	:	US
Telephone Number	:	516-427-9582
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS
Name	:	MALKA ROSENZWEIG
Credential	:
Telephone Number	:	518-275-9654

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/09/2024

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