Provider Demographics
NPI:1295386159
Name:THE AUTISM BEHAVIOR CONNECTION LLC
Entity Type:Organization
Organization Name:THE AUTISM BEHAVIOR CONNECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:ALANA
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:803-546-6922
Mailing Address - Street 1:110 STEPHANEE LN
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29130-9408
Mailing Address - Country:US
Mailing Address - Phone:803-546-6922
Mailing Address - Fax:
Practice Address - Street 1:110 STEPHANEE LN
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-9408
Practice Address - Country:US
Practice Address - Phone:803-546-6922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-28107OtherBEHAVIOR ANALYST CERTIFICATION BOARD