Basic Information
| Provider Information | |||||||||
| NPI: | 1750951430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARTLETT REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BARTLETT HOSPITAL ABA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968900 | ||||||||
| FaxNumber: | 9077968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 HOSPITAL DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968272 | ||||||||
| FaxNumber: | 9077968497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2021 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEITH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | NEIL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9077968900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BARTLETT REGIONAL HOSPITAL | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.