Provider Demographics
NPI:1760923437
Name:BEHAVIOR MODIFICATION SOLUTIONS ABA, LLC
Entity Type:Organization
Organization Name:BEHAVIOR MODIFICATION SOLUTIONS ABA, LLC
Other - Org Name:ON EAGLES WINGS ABA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEARSON
Authorized Official - Middle Name:FOSS
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:956-454-8539
Mailing Address - Street 1:1941 CRAPE MYRTLE LOOP APT 205
Mailing Address - Street 2:205
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4008
Mailing Address - Country:US
Mailing Address - Phone:956-454-8539
Mailing Address - Fax:
Practice Address - Street 1:1941 CRAPE MYRTLE LOOP
Practice Address - Street 2:205
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549
Practice Address - Country:US
Practice Address - Phone:956-454-8539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10524103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017539500Medicaid