Provider Demographics
NPI:1457060071
Name:SUPPORTIVE CARE ABA NC LLC
Entity Type:Organization
Organization Name:SUPPORTIVE CARE ABA NC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KESHERIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-936-1240
Mailing Address - Street 1:104 S WHITE ST STE 150
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 S WHITE ST STE 150
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2773
Practice Address - Country:US
Practice Address - Phone:317-936-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-22
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty