Provider Demographics
NPI:1760838015
Name:CHRYSALIS ABA THERAPY CORP
Entity Type:Organization
Organization Name:CHRYSALIS ABA THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEATRIZ
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOURACLES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, BCBA, LBA, IBA
Authorized Official - Phone:617-470-9827
Mailing Address - Street 1:5180 W ATLANTIC AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8103
Mailing Address - Country:US
Mailing Address - Phone:561-359-3815
Mailing Address - Fax:561-816-4315
Practice Address - Street 1:5180 W ATLANTIC AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8103
Practice Address - Country:US
Practice Address - Phone:561-674-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017416600Medicaid