Provider Demographics
NPI:1477254472
Name:THIRD WAVE ABA LLC
Entity Type:Organization
Organization Name:THIRD WAVE ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:831-531-7123
Mailing Address - Street 1:161 PEREGRINE LN
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9770
Mailing Address - Country:US
Mailing Address - Phone:408-835-2440
Mailing Address - Fax:
Practice Address - Street 1:161 PEREGRINE LN
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-9770
Practice Address - Country:US
Practice Address - Phone:408-835-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty