Provider Demographics
NPI:1497532071
Name:LEAP FORWARD AUTISM SERVICES LLC
Entity Type:Organization
Organization Name:LEAP FORWARD AUTISM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTWANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:757-593-5662
Mailing Address - Street 1:6303 SAINT CLAIR DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2677
Mailing Address - Country:US
Mailing Address - Phone:757-593-5662
Mailing Address - Fax:
Practice Address - Street 1:6303 SAINT CLAIR DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2677
Practice Address - Country:US
Practice Address - Phone:757-593-5662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-08
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty