MEDICARE: ROGUE ABA ARIZONA 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	251S00000X	Community/Behavioral Health Agency
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1821831942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGUE ABA ARIZONA LLC

Provider Business Mailing Address
First Line	:	2760 W PEORIA AVE STE 1061
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-5202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 W PEORIA AVE STE 1061
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-5202
Country	:	US
Telephone Number	:	603-692-8173
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CF TRUE
Credential	:
Telephone Number	:	603-692-8173

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/17/2024

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