Provider Demographics
NPI:1316693716
Name:GENESIS ABA, LLC
Entity type:Organization
Organization Name:GENESIS ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:815-999-1524
Mailing Address - Street 1:1650 ASHBURY LN
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4887
Mailing Address - Country:US
Mailing Address - Phone:815-999-1524
Mailing Address - Fax:
Practice Address - Street 1:1650 ASHBURY LN
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4887
Practice Address - Country:US
Practice Address - Phone:815-999-1524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty