Provider Demographics
NPI:1568804029
Name:KTL BEHAVIORAL THERAPY & CONSULTATION PLLC
Entity Type:Organization
Organization Name:KTL BEHAVIORAL THERAPY & CONSULTATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARD MOON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:763-439-0303
Mailing Address - Street 1:1603 SANCHEZ ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-1640
Mailing Address - Country:US
Mailing Address - Phone:763-439-0303
Mailing Address - Fax:
Practice Address - Street 1:1603 SANCHEZ ST
Practice Address - Street 2:UNIT A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-1640
Practice Address - Country:US
Practice Address - Phone:763-439-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty