Basic Information
| Provider Information | |||||||||
| NPI: | 1811322092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABA AT LEGACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19751 E. MAINSTREET STE. 215 | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038414005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19751 E. MAINSTREET STE. 215 | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038414005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2013 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3038414005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D., BCBA-D | ||||||||
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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.