Provider Demographics
NPI:1821543141
Name:CLINICAL BEHAVIOR ANALYSIS
Entity Type:Organization
Organization Name:CLINICAL BEHAVIOR ANALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY SYSTEM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-409-7181
Mailing Address - Street 1:800 W WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2472
Mailing Address - Country:US
Mailing Address - Phone:502-409-7181
Mailing Address - Fax:888-450-0935
Practice Address - Street 1:1601 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1327
Practice Address - Country:US
Practice Address - Phone:502-409-7181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY167209103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100343010Medicaid