Provider Demographics
NPI:1437431624
Name:FUNDAMENTAL BEHAVIOR SERVICES, LLC
Entity Type:Organization
Organization Name:FUNDAMENTAL BEHAVIOR SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:240-361-7178
Mailing Address - Street 1:554 N FREDERICK AVE # 345
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2504
Mailing Address - Country:US
Mailing Address - Phone:240-361-7178
Mailing Address - Fax:
Practice Address - Street 1:554 N FREDERICK AVE # 345
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2504
Practice Address - Country:US
Practice Address - Phone:240-361-7178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-11-8537103K00000X
251C00000X, 251S00000X, 252Y00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty