Provider Demographics
NPI:1629547732
Name:INDEPENDENCE ABA THERAPY, LLC
Entity Type:Organization
Organization Name:INDEPENDENCE ABA THERAPY, LLC
Other - Org Name:INDEPENDENCE ABA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA
Authorized Official - Phone:714-403-8186
Mailing Address - Street 1:5 E BIJOU ST STE 116
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1301
Mailing Address - Country:US
Mailing Address - Phone:714-403-8186
Mailing Address - Fax:855-719-3133
Practice Address - Street 1:5 E BIJOU ST STE 116
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1301
Practice Address - Country:US
Practice Address - Phone:714-403-8186
Practice Address - Fax:855-719-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty