Provider Demographics
NPI:1710691050
Name:SOCIALSPACE ABA THERAPY LLC
Entity Type:Organization
Organization Name:SOCIALSPACE ABA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SIKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-897-5496
Mailing Address - Street 1:4112 WETHERFIELD CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-8035
Mailing Address - Country:US
Mailing Address - Phone:870-897-5496
Mailing Address - Fax:
Practice Address - Street 1:4112 WETHERFIELD CV
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8035
Practice Address - Country:US
Practice Address - Phone:870-897-5496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty