Provider Demographics
NPI:1093250060
Name:MOUNTAIN STATE APPLIED BEHAVIOR ANALYSIS LLC
Entity Type:Organization
Organization Name:MOUNTAIN STATE APPLIED BEHAVIOR ANALYSIS LLC
Other - Org Name:MOUNTAIN STATE ABA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EZRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-290-4262
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-0442
Mailing Address - Country:US
Mailing Address - Phone:304-290-4262
Mailing Address - Fax:304-212-0627
Practice Address - Street 1:1010 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-1683
Practice Address - Country:US
Practice Address - Phone:304-290-4262
Practice Address - Fax:304-212-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1-14-16309103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty