Provider Demographics
NPI:1942063417
Name:AMTH9085
Entity Type:Organization
Organization Name:AMTH9085
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUM-KASIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA (ND)
Authorized Official - Phone:701-333-8675
Mailing Address - Street 1:25 36TH AVENUE CIR S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5558
Mailing Address - Country:US
Mailing Address - Phone:701-333-8675
Mailing Address - Fax:
Practice Address - Street 1:25 36TH AVENUE CIR S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5558
Practice Address - Country:US
Practice Address - Phone:701-333-8675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty