Basic Information
| Provider Information | |||||||||
| NPI: | 1639401375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTISM BEHAVIOR CONSULTING GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1162 | ||||||||
| Address2: | |||||||||
| City: | WAIALUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967911162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086377736 | ||||||||
| FaxNumber: | 8087480202 | ||||||||
| Practice Location | |||||||||
| Address1: | 66-434 KAMEHAMEHA HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | HALEIWA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082777736 | ||||||||
| FaxNumber: | 8087480202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2010 | ||||||||
| LastUpdateDate: | 01/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | WIECH | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8082777736 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1041581 | HI | N | Agencies | Community/Behavioral Health | 251C00000X | 1041581 | HI | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 1245426865 | 01 | TRICARE | OTHER |