Provider Demographics
NPI:1417524307
Name:A LEAP BEYOND AUTISM SERVICES, LLC
Entity Type:Organization
Organization Name:A LEAP BEYOND AUTISM SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIA
Authorized Official - Middle Name:CHALISE
Authorized Official - Last Name:PENN-TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-966-3933
Mailing Address - Street 1:100 COMMERCE DR UNIT 452
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-8020
Mailing Address - Country:US
Mailing Address - Phone:404-966-3933
Mailing Address - Fax:
Practice Address - Street 1:110 NEWFIELD DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2567
Practice Address - Country:US
Practice Address - Phone:678-862-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8837997616Medicaid