Provider Demographics
NPI:1407453749
Name:SOUTHLAKE HB ABA SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHLAKE HB ABA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MEMBER
Authorized Official - Phone:713-591-2256
Mailing Address - Street 1:940 S KIMBALL AVE STE 175
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9024
Mailing Address - Country:US
Mailing Address - Phone:210-680-5033
Mailing Address - Fax:
Practice Address - Street 1:940 S KIMBALL AVE STE 175
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9024
Practice Address - Country:US
Practice Address - Phone:210-680-5033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty