Provider Demographics
NPI:1043780695
Name:PROUD MOMENTS ABA OF NEVADA LLC
Entity Type:Organization
Organization Name:PROUD MOMENTS ABA OF NEVADA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDFEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-215-5311
Mailing Address - Street 1:1449 37 STREET SUITE 100
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:
Practice Address - Street 1:1775 VILLAGE CENTER CIR STE 190
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-0571
Practice Address - Country:US
Practice Address - Phone:877-768-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-13-13480OtherBACB