Provider Demographics
NPI:1518541713
Name:TOTAL BEHAVIOR SUPPORT LLC
Entity Type:Organization
Organization Name:TOTAL BEHAVIOR SUPPORT LLC
Other - Org Name:TOTAL BEHAVIOR SUPPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:NICCOLE
Authorized Official - Last Name:KORNELIS
Authorized Official - Suffix:
Authorized Official - Credentials:LBA
Authorized Official - Phone:707-450-7587
Mailing Address - Street 1:1015 S BROADWAY STE 16
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:707-450-7587
Mailing Address - Fax:
Practice Address - Street 1:1015 S BROADWAY STE 16
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:707-450-7587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-12
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDL78OtherBEHAVIOR ANALYST LICENSE