Basic Information
Provider Information | |||||||||
NPI: | 1205251089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FURLONG | ||||||||
FirstName: | NAOMI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MEULINK | ||||||||
OtherFirstName: | NAOMI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 390 UNION BLVD STE 300 | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802286514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039898169 | ||||||||
FaxNumber: | 3039844366 | ||||||||
Practice Location | |||||||||
Address1: | 6369 E TANQUE VERDE RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857153833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039898169 | ||||||||
FaxNumber: | 3039844366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2014 | ||||||||
LastUpdateDate: | 10/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BEH-000746 | AZ | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 103K00000X | 1-18-30256 | CO | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 106S00000X | 05 | OR |   | MEDICAID |