Provider Demographics
NPI:1336529742
Name:REVOLUTION ABA LLC
Entity type:Organization
Organization Name:REVOLUTION ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BREANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:720-982-7888
Mailing Address - Street 1:200 N VINEYARD BLVD STE A325 #5429
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817
Mailing Address - Country:US
Mailing Address - Phone:808-207-5272
Mailing Address - Fax:
Practice Address - Street 1:200 N VINEYARD BLVD STE A325 #5429
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817
Practice Address - Country:US
Practice Address - Phone:808-207-5272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-14-15946103K00000X, 251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91680069Medicaid