Basic Information
| Provider Information | |||||||||
| NPI: | 1295121374 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED LEARNING ACADEMY NEWTON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | APPLIED BEHAVIORAL LEARNING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 109 OAK ST | ||||||||
| Address2: | SUITE G10 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179165573 | ||||||||
| FaxNumber: | 6179165081 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 OAK ST | ||||||||
| Address2: | SUITE G10 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179165573 | ||||||||
| FaxNumber: | 6179165081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VARGAS | ||||||||
| AuthorizedOfficialFirstName: | MARIELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6179165573 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BCBA, PYS-D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 7783 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.