Provider Demographics
NPI: | 1619442522 |
---|---|
Name: | BLACK HILLS BEHAVIOR, LLC |
Entity Type: | Organization |
Organization Name: | BLACK HILLS BEHAVIOR, LLC |
Other - Org Name: | IMPACT LEARNING & DEVELOPMENT |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | NANCY |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | PRUITT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MS, BCBA, LBA |
Authorized Official - Phone: | 605-206-5004 |
Mailing Address - Street 1: | 2475 W CHICAGO ST |
Mailing Address - Street 2: | |
Mailing Address - City: | RAPID CITY |
Mailing Address - State: | SD |
Mailing Address - Zip Code: | 57702-2467 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 605-206-5004 |
Mailing Address - Fax: | 605-646-4840 |
Practice Address - Street 1: | 2475 W CHICAGO ST |
Practice Address - Street 2: | |
Practice Address - City: | RAPID CITY |
Practice Address - State: | SD |
Practice Address - Zip Code: | 57702-2467 |
Practice Address - Country: | US |
Practice Address - Phone: | 605-206-5004 |
Practice Address - Fax: | 605-646-4840 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-10-06 |
Last Update Date: | 2021-04-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
No | 106E00000X | Behavioral Health & Social Service Providers | Assistant Behavior Analyst | Group - Multi-Specialty | |
No | 106S00000X | Behavioral Health & Social Service Providers | Behavior Technician | Group - Multi-Specialty | |
No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | Group - Multi-Specialty |
No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | Group - Multi-Specialty |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |