Provider Demographics
NPI:1609463298
Name:FUNDAMENTAL ABA THERAPY,LLC
Entity Type:Organization
Organization Name:FUNDAMENTAL ABA THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:754-422-2165
Mailing Address - Street 1:5529 NW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7776
Mailing Address - Country:US
Mailing Address - Phone:754-422-2165
Mailing Address - Fax:
Practice Address - Street 1:8053 W OAKLAND PARK BLVD STE 950
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-1162
Practice Address - Country:US
Practice Address - Phone:754-422-2165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty