Basic Information
| Provider Information | |||||||||
| NPI: | 1912639154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUT OF THE BOX CLINICAL BEHAVIOR ANALYSIS AND COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W LOMBARD ST APT 612 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104181211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 W LOMBARD ST APT 612 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104181211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2022 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | JAMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BCBA, CLINICAL | ||||||||
| AuthorizedOfficialTelephone: | 5104181211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 133004700 | 05 | MD | MEDICAID |