Provider Demographics
NPI:1467836718
Name:ABA CONQUEST, LLC
Entity Type:Organization
Organization Name:ABA CONQUEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-349-1186
Mailing Address - Street 1:1365 SW VIZCAYA CIR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-1962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1365 SW VIZCAYA CIR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1962
Practice Address - Country:US
Practice Address - Phone:772-349-1186
Practice Address - Fax:772-324-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-14-16478251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251S00000XAgenciesCommunity/Behavioral Health