Provider Demographics
NPI:1790295350
Name:SOUTHERN OREGON ABA
Entity Type:Organization
Organization Name:SOUTHERN OREGON ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKOLE
Authorized Official - Middle Name:APRIL
Authorized Official - Last Name:MCEWEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:541-727-1592
Mailing Address - Street 1:2030 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1762
Mailing Address - Country:US
Mailing Address - Phone:541-727-1592
Mailing Address - Fax:541-664-3407
Practice Address - Street 1:2030 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-1762
Practice Address - Country:US
Practice Address - Phone:541-727-1592
Practice Address - Fax:541-664-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-B-10175208103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty