Provider Demographics
NPI:1194415612
Name:MISSION MOMENTUM ABA, INC.
Entity type:Organization
Organization Name:MISSION MOMENTUM ABA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-279-2443
Mailing Address - Street 1:2475 PLUMADORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-9012
Mailing Address - Country:US
Mailing Address - Phone:321-279-2443
Mailing Address - Fax:
Practice Address - Street 1:2475 PLUMADORE DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32735-9012
Practice Address - Country:US
Practice Address - Phone:321-279-2443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty