Provider Demographics
NPI:1689194615
Name:NEW WAVE BEHAVIOR MANAGEMENT, LLC.
Entity Type:Organization
Organization Name:NEW WAVE BEHAVIOR MANAGEMENT, LLC.
Other - Org Name:A.I.D. BEHAVIOR MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:260-557-5518
Mailing Address - Street 1:PO BOX 10362
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46852-0362
Mailing Address - Country:US
Mailing Address - Phone:260-557-5519
Mailing Address - Fax:
Practice Address - Street 1:4610 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-2721
Practice Address - Country:US
Practice Address - Phone:765-207-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========Medicaid