Provider Demographics
NPI:1306133681
Name:CHILD'S PLAY BEHAVIOR ANALYSIS
Entity type:Organization
Organization Name:CHILD'S PLAY BEHAVIOR ANALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE-ROSE
Authorized Official - Last Name:FULCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:423-582-9494
Mailing Address - Street 1:670 CHADINGS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-8875
Mailing Address - Country:US
Mailing Address - Phone:423-582-9494
Mailing Address - Fax:
Practice Address - Street 1:670 CHADINGS DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-8875
Practice Address - Country:US
Practice Address - Phone:423-582-9494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1107501103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty