Provider Demographics
NPI:1770219891
Name:PANTHEON ABA, LLC
Entity Type:Organization
Organization Name:PANTHEON ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KURTZUBA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LBA, BCBA
Authorized Official - Phone:318-554-8348
Mailing Address - Street 1:5154 GARLAND DR APT 2
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-6069
Mailing Address - Country:US
Mailing Address - Phone:318-554-8348
Mailing Address - Fax:
Practice Address - Street 1:5154 GARLAND DR APT A
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-6069
Practice Address - Country:US
Practice Address - Phone:318-554-8348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty