Provider Demographics
NPI:1598477879
Name:BASELINE LOGIC LLC
Entity Type:Organization
Organization Name:BASELINE LOGIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:SHRIVASTAV
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:812-345-6388
Mailing Address - Street 1:2815 E 3RD ST # 1011
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5434
Mailing Address - Country:US
Mailing Address - Phone:812-345-6388
Mailing Address - Fax:
Practice Address - Street 1:4438 E ELOUISE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-3202
Practice Address - Country:US
Practice Address - Phone:812-345-6388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty