Provider Demographics
NPI:1346863529
Name:INNOVATE ABA
Entity Type:Organization
Organization Name:INNOVATE ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAWANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA
Authorized Official - Phone:714-580-5969
Mailing Address - Street 1:5405 ALTON PKWY STE 5A
Mailing Address - Street 2:#430
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 ALTON PKWY STE 5A
Practice Address - Street 2:#430
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3717
Practice Address - Country:US
Practice Address - Phone:714-580-5969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty