Provider Demographics
NPI:1194472787
Name:PHOENIX ABA SERVICES
Entity Type:Organization
Organization Name:PHOENIX ABA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:817-948-9367
Mailing Address - Street 1:3920 DREXMORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8510
Mailing Address - Country:US
Mailing Address - Phone:817-948-9367
Mailing Address - Fax:
Practice Address - Street 1:1540 KELLER PKWY STE 108136
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3686
Practice Address - Country:US
Practice Address - Phone:682-593-3182
Practice Address - Fax:817-438-1426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty