Provider Demographics
NPI:1639704372
Name:WILLOW ABA SERVICES LLC
Entity type:Organization
Organization Name:WILLOW ABA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:SIERKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-375-3626
Mailing Address - Street 1:7150 CAMPUS DR STE 290
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-6508
Mailing Address - Country:US
Mailing Address - Phone:913-375-3626
Mailing Address - Fax:
Practice Address - Street 1:2815 EXCHANGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7515
Practice Address - Country:US
Practice Address - Phone:913-375-3626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty