Provider Demographics
NPI:1336606755
Name:ABA OF PORTLAND CORP.
Entity Type:Organization
Organization Name:ABA OF PORTLAND CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:BRUZUAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-569-3941
Mailing Address - Street 1:11304 SE 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6764
Mailing Address - Country:US
Mailing Address - Phone:786-569-3941
Mailing Address - Fax:888-391-5328
Practice Address - Street 1:11304 SE 35TH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6764
Practice Address - Country:US
Practice Address - Phone:786-569-3941
Practice Address - Fax:888-391-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty