Provider Demographics
NPI:1376201483
Name:ABA PEDIATRIC AUTISM SERVICES
Entity Type:Organization
Organization Name:ABA PEDIATRIC AUTISM SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / BCBA
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:312-802-0967
Mailing Address - Street 1:872 SHEPARD CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2715
Mailing Address - Country:US
Mailing Address - Phone:312-802-0967
Mailing Address - Fax:
Practice Address - Street 1:872 SHEPARD CREEK PKWY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2715
Practice Address - Country:US
Practice Address - Phone:312-802-0967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-06
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty