Provider Demographics
NPI:1356109086
Name:AVITA THERAPY SERVICES
Entity type:Organization
Organization Name:AVITA THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:925-639-0419
Mailing Address - Street 1:110 BUTTERCUP CV
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-6106
Mailing Address - Country:US
Mailing Address - Phone:925-639-0419
Mailing Address - Fax:
Practice Address - Street 1:110 BUTTERCUP CV
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-6106
Practice Address - Country:US
Practice Address - Phone:925-639-0419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty