Basic Information
Provider Information | |||||||||
NPI: | 1053598797 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AGARWAL | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | REBECCA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BIERMAN | ||||||||
OtherFirstName: | COURTNEY | ||||||||
OtherMiddleName: | REBECCA | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 16414 SOUTHPARK DR | ||||||||
Address2: |   | ||||||||
City: | WESTFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 460748396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178155501 | ||||||||
FaxNumber: | 3173997935 | ||||||||
Practice Location | |||||||||
Address1: | 16414 SOUTHPARK DR | ||||||||
Address2: |   | ||||||||
City: | WESTFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 460748396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178155501 | ||||||||
FaxNumber: | 3173997935 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2008 | ||||||||
LastUpdateDate: | 02/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-11-9389 | IN | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.