Provider Demographics
NPI:1356127997
Name:MANKATO FULL SPECTRUM ABA
Entity type:Organization
Organization Name:MANKATO FULL SPECTRUM ABA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULLAHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-351-1034
Mailing Address - Street 1:2140 HOFFMAN RD
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5863
Mailing Address - Country:US
Mailing Address - Phone:507-351-1034
Mailing Address - Fax:
Practice Address - Street 1:2140 HOFFMAN RD
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5863
Practice Address - Country:US
Practice Address - Phone:507-351-1034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty