Provider Demographics
NPI:1154088417
Name:SHAPE BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:SHAPE BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:KISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-281-4333
Mailing Address - Street 1:625 S L ROGERS WELLS BLVD # 218
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1074
Mailing Address - Country:US
Mailing Address - Phone:423-281-4333
Mailing Address - Fax:
Practice Address - Street 1:625 S L ROGERS WELLS BLVD # 218
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1074
Practice Address - Country:US
Practice Address - Phone:423-281-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty