Basic Information
| Provider Information | |||||||||
| NPI: | 1053838011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELFRIDGE | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 N DURANGO DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810072193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197787012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5526 N ACADEMY BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193015100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2017 | ||||||||
| LastUpdateDate: | 03/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-17-36922 | N | 103K00000X | 1-19-34939 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-19-34939 | 01 | BACB | OTHER | RBT-17-36922 | 01 | BACB | OTHER |