Provider Demographics
NPI:1780249664
Name:FRAGILE X LIFE, ABA GROUP
Entity type:Organization
Organization Name:FRAGILE X LIFE, ABA GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:TIMICA
Authorized Official - Middle Name:ROSSETTA
Authorized Official - Last Name:RADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:760-801-2015
Mailing Address - Street 1:PO BOX 2137
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-2137
Mailing Address - Country:US
Mailing Address - Phone:760-801-2015
Mailing Address - Fax:
Practice Address - Street 1:26907 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-6662
Practice Address - Country:US
Practice Address - Phone:760-801-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty