Provider Demographics
NPI:1740813708
Name:UPSTATE APPLIED BEHAVIOR ANALYSIS SERVICES PLLC
Entity type:Organization
Organization Name:UPSTATE APPLIED BEHAVIOR ANALYSIS SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:518-605-3146
Mailing Address - Street 1:35 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8044
Mailing Address - Country:US
Mailing Address - Phone:518-605-3146
Mailing Address - Fax:
Practice Address - Street 1:35 REVERE RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-8044
Practice Address - Country:US
Practice Address - Phone:518-605-3146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty