Provider Demographics
NPI:1306394291
Name:MARIN AUTISM INTERVENTIONS, LLC.
Entity Type:Organization
Organization Name:MARIN AUTISM INTERVENTIONS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED BEHAVIOR ANALYST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRIDDY-MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:310-560-9270
Mailing Address - Street 1:228 EMMANUEL WAY LN
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:KY
Mailing Address - Zip Code:40176-5037
Mailing Address - Country:US
Mailing Address - Phone:310-560-9270
Mailing Address - Fax:
Practice Address - Street 1:228 EMMANUEL WAY LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:KY
Practice Address - Zip Code:40176-5037
Practice Address - Country:US
Practice Address - Phone:310-560-9270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101578103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100360170Medicaid