Provider Demographics
NPI:1407358609
Name:MOMENTUM ABA THERAPY
Entity Type:Organization
Organization Name:MOMENTUM ABA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:NCBA
Authorized Official - Phone:901-314-9722
Mailing Address - Street 1:2125 LEICHESTER LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-6971
Mailing Address - Country:US
Mailing Address - Phone:901-314-9722
Mailing Address - Fax:
Practice Address - Street 1:2125 LEICHESTER LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-6971
Practice Address - Country:US
Practice Address - Phone:901-314-9722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11725115103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ034006Medicaid