Provider Demographics
NPI:1912663998
Name:AUTISM BEHAVIORAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:AUTISM BEHAVIORAL ASSOCIATES LLC
Other - Org Name:DIVERGENT ABILITIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-FOUNDER/BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:512-550-7472
Mailing Address - Street 1:102 E OLD BOWMAN RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2296
Mailing Address - Country:US
Mailing Address - Phone:512-931-1238
Mailing Address - Fax:512-287-5565
Practice Address - Street 1:102 E OLD BOWMAN RD STE A
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2296
Practice Address - Country:US
Practice Address - Phone:512-931-1238
Practice Address - Fax:512-287-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-13
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4314395Medicaid