Provider Demographics
NPI:1740889823
Name:INFINITE CHANGES ABA THERAPY & AUTISM SERVICES
Entity type:Organization
Organization Name:INFINITE CHANGES ABA THERAPY & AUTISM SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:FREDRICCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:901-606-5038
Mailing Address - Street 1:8481 REGAL BEND DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4416
Mailing Address - Country:US
Mailing Address - Phone:901-606-5038
Mailing Address - Fax:
Practice Address - Street 1:5115 COVINGTON WAY STE 5
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-5619
Practice Address - Country:US
Practice Address - Phone:901-606-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty