MEDICARE: PHILLY ABA THERAPY 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	:	1861184780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLY ABA THERAPY LLC

Provider Business Mailing Address
First Line	:	7244 CASTOR AVE # 8201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1109
Country	:	US
Telephone Number	:	215-960-0174
Fax Number	:

Provider Business Practice Location Address
First Line	:	7244 CASTOR AVE # 8201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1109
Country	:	US
Telephone Number	:	215-960-0174
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. VLADIMIR KOGAN
Credential	:
Telephone Number	:	215-960-0174

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/22/2023

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