Provider Demographics
NPI:1558993220
Name:EXPERIENTIAL LEARNING ABA LLC
Entity Type:Organization
Organization Name:EXPERIENTIAL LEARNING ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNE/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETEFISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-319-7098
Mailing Address - Street 1:201 BRIERTON LN
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1946
Mailing Address - Country:US
Mailing Address - Phone:314-319-7098
Mailing Address - Fax:866-591-9660
Practice Address - Street 1:201 BRIERTON LN
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1946
Practice Address - Country:US
Practice Address - Phone:314-319-7098
Practice Address - Fax:866-591-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty