Provider Demographics
NPI:1780044404
Name:FUNCTIONAL BEHAVIOR SERVICES, LLC
Entity Type:Organization
Organization Name:FUNCTIONAL BEHAVIOR SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:CARRISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LLMSW
Authorized Official - Phone:069-273-1121
Mailing Address - Street 1:N5625 NUMMELA RD
Mailing Address - Street 2:
Mailing Address - City:SKANDIA
Mailing Address - State:MI
Mailing Address - Zip Code:49885-9755
Mailing Address - Country:US
Mailing Address - Phone:906-439-5290
Mailing Address - Fax:906-439-5279
Practice Address - Street 1:1229 W WASHINGTON ST STE 5
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3186
Practice Address - Country:US
Practice Address - Phone:906-273-1121
Practice Address - Fax:906-225-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-14-15411103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty