Provider Demographics
NPI:1376296392
Name:TO THE MAX BEHAVIOR THERAPY, LLC
Entity Type:Organization
Organization Name:TO THE MAX BEHAVIOR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:
Authorized Official - First Name:NISA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-316-3487
Mailing Address - Street 1:4225 BENTTREE DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-8669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4225 BENTTREE DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-8669
Practice Address - Country:US
Practice Address - Phone:270-240-2846
Practice Address - Fax:270-246-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100461110Medicaid