Provider Demographics
NPI:1851157762
Name:MAGIC VALLEY ABA THERAPY LLC
Entity Type:Organization
Organization Name:MAGIC VALLEY ABA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:208-421-7096
Mailing Address - Street 1:161 W ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:HAGERMAN
Mailing Address - State:ID
Mailing Address - Zip Code:83332-5064
Mailing Address - Country:US
Mailing Address - Phone:208-421-7096
Mailing Address - Fax:
Practice Address - Street 1:161 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:HAGERMAN
Practice Address - State:ID
Practice Address - Zip Code:83332-5064
Practice Address - Country:US
Practice Address - Phone:208-421-7096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215511639Medicaid