Provider Demographics
NPI:1326883521
Name:MOUNTAIN WAVES ABA, LLC
Entity type:Organization
Organization Name:MOUNTAIN WAVES ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:HARD
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:540-915-4767
Mailing Address - Street 1:730 CAMP NORTH RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3046
Mailing Address - Country:US
Mailing Address - Phone:540-915-4767
Mailing Address - Fax:540-202-9002
Practice Address - Street 1:6746 THIRLANE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2908
Practice Address - Country:US
Practice Address - Phone:540-915-4767
Practice Address - Fax:540-202-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609355809Medicaid
VA30016163330003Medicaid
VA30017464310001Medicaid
VA1134854946Medicaid
VA1811418668Medicaid