MEDICARE: FOOTHILLS AUTISM SERVICES 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	:	1962219139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHILLS AUTISM SERVICES ABA LLC

Provider Business Mailing Address
First Line	:	209 EASTWOOD PARK CIR SE
Second Line	:
City	:	LENOIR
State	:	NC
Zip	:	28645-6212
Country	:	US
Telephone Number	:	828-999-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 EASTWOOD PARK CIR SE
Second Line	:
City	:	LENOIR
State	:	NC
Zip	:	28645-6212
Country	:	US
Telephone Number	:	828-999-0355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATELYN O'HEARN
Credential	:	BCBA, LBA
Telephone Number	:	828-999-0355

Provider Enumeration Date	:	12/11/2024
Last Update Date	:	12/11/2024

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