Provider Demographics
NPI:1093980278
Name:AUTISM AND BEHAVIOR SERVICES
Entity Type:Organization
Organization Name:AUTISM AND BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/BEHAVIOR ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORKUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D
Authorized Official - Phone:423-664-0901
Mailing Address - Street 1:3131 QUIET CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-4009
Mailing Address - Country:US
Mailing Address - Phone:423-664-0903
Mailing Address - Fax:423-602-9710
Practice Address - Street 1:3131 QUIET CREEK TRL
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-4009
Practice Address - Country:US
Practice Address - Phone:423-664-0903
Practice Address - Fax:423-602-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509613Medicaid