1780044404 NPI number — FUNCTIONAL BEHAVIOR SERVICES, LLC

Table of content: (NPI 1780044404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780044404 NPI number — FUNCTIONAL BEHAVIOR SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL BEHAVIOR SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780044404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N5625 NUMMELA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKANDIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49885-9755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-439-5290
Provider Business Mailing Address Fax Number:
906-439-5279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1229 W WASHINGTON ST STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-3186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-273-1121
Provider Business Practice Location Address Fax Number:
906-225-6706
Provider Enumeration Date:
02/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RONDEAU
Authorized Official First Name:
CARRISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
BCBA
Authorized Official Telephone Number:
69-273-1121

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-14-15411 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com