Provider Demographics
NPI:1972021806
Name:ALLEY, TAVIA RENEE (BCBA)
Entity Type:Individual
Prefix:
First Name:TAVIA
Middle Name:RENEE
Last Name:ALLEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5556 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-2658
Mailing Address - Country:US
Mailing Address - Phone:317-334-7331
Mailing Address - Fax:317-334-7336
Practice Address - Street 1:21613 RHODES RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-3026
Practice Address - Country:US
Practice Address - Phone:281-407-1690
Practice Address - Fax:317-334-7336
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-30210106S00000X
CO1-19-37085103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1972021806Medicaid