Provider Demographics
NPI:1235886466
Name:ALLAY BEHAVIORAL THERAPY, LLC
Entity Type:Organization
Organization Name:ALLAY BEHAVIORAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:614-900-2403
Mailing Address - Street 1:1750 TREE BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5719
Mailing Address - Country:US
Mailing Address - Phone:904-206-7024
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5719
Practice Address - Country:US
Practice Address - Phone:904-206-7024
Practice Address - Fax:866-374-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty